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ESSENTIALS 

OF THE 
\ 

I PRINCIPLES AND PRACTICE 

OF 

MEDICINE. 



WORKS ON THE PRACTICE OF MEDICINE. 



A TREATISE ON THE PRINCIPLES AND PRACTICE OF 

MEDICINE. Designed for the use of Students and Practitioners of Medi- 
cine. By Austin Flint, M. D., Professor of the Principles and Practice of 
Medicine in Bellevue Med. College, N. Y. Second edition, revised and en- 
larged. In one large and closely printed octavo volume of nearly 1000 
pages. Handsome extra cloth, $6 50 ; or, strongly bound in leather, with 
raised bands, $7 50. {Just Issued.) 

We are happy in being able once more to commend this work to the students and prac- 
titioners of medicine who seek for accurate information conveyed in language at once 
clear, precise, and expressive. — Am. Jour. Med. Sciences, April, 1867. 

Dr. Flint, who has been known in this country for many years, both as an author and 
teacher, who has discovered truth, and pointed it out clearly and distinctly to others, 
investigated the symptoms and natural history of disease and recorded its language and 
facts, and devoted a life of incessant study and thought to the doubtful or obscure in his 
profession, has at length, in his ripe scholarship, given this work to the profession as a 
crowning gift. If we have spoken highly of its value to the profession and world ; if we 
have said, all considered, it is the very best work upon medical practice in any lan- 
guage; if we have spoken of its excellences in detail, and given points of special value, 
we have yet failed to express in any degree our present estimate of its value as a guide 
in the practice of medicine. It does noVcontain too much or too little ; it is not positive 
where doubt should be expressed, or Hesitate where truth is known. It is philosophical 
and speculative where philosophy and speculation are all that can at present be ob- 
tained, but nothing is admitted to the elevation of established truth, without the most 
thorough investigation. It is truly remarkable with what even hand this work has 
been written, and how it all shows the most careful thought and untiring study. We 
conclude that, though it may yet be susceptible of improvement, it still constitutes the 
very best which human knowledge can at present produce. "When knowledge is in- 
creased," the work will doubtless be^again revised ; meanwhile we shall accept it as 
the rule of practice. — Buffalo Med. and Surg. Journal, Feb. 1867. 



LECTURES ON THE PRINCIPLES AND PRACTICE OF 
PHYSIC. Delivered at King's College, London. By Sir Thomas Watson, 
M. D., &c. A new American, from the last revised and enlarged English 
edition, with Additions, by D. Francis Condie, M. D , author of " A Prac- 
tical Treatise on the Diseases, of Children," &c. With one hundred and 
eighty-five illustrations on wood. In one very large and handsome volume,, 
imperial octavo, of over 1200 closely printed pages in small type ; extra 
cloth, $6 50; strongly bound in leather, with raised bands, $7 50. 
Believing this to be a work which should lie on the table of every physician, 
and be in the hands of every student, every effort has been made to condense 
the vast amount of matter which it contains within a convenient compass, and 
at a very reasonable price, to place it within reach of all. In its present en- 
larged form, the work contains the matter of at least three ordinary octavos, 
rendering it one of the cheapest works now offered to the American profession, 
while its mechanical execution ma^es it an exceedingly attractive volume. 



ELEMENTS OF MEDICINE. A Compendious View of Patho- 
logy and Therapeutics, or the History and Treatment of Diseases. By Samuel 
H. Dickson, M.D., Professor of Practice of Medicine in Jefferson Medical 
College, Philadelphia. Second edition, revised. In one large and handsome 
octavo volume of 750 pages, extra cloth. $4 00. 



THE CYCLOPAEDIA OF PRACTICAL MEDICINE. Com- 

prising Treatises on the Nature and Treatment of Diseases, Materia Medica 
and Therapeutics, Diseases of Women and Children, Medical Jurisprudence, 
&c. &c. Edited by Drs. Forbes, Tweedie, and Connolly, and Revised by 
Robley Dungltson, M. D. In four large super-royal octavo volumes of 
3254 double-columned pages, strongly and handsomely bound. $15 00. 
*%* This work contains no less than four hundred and eighteen distinct 
treatises, contributed by sixty-eight distinguished physicians. 

HENRY C. LEA, Philadelphia. 



ESSENTIALS 

OF THE 

PRINCIPLES AND PRACTICE 

OF 

MEDICINE. 

A 

HA]S T DY-BOOK 

FOR 

STUDENTS AND PRACTITIONERS. 



/ BY 
HENRY HARTSHORNE, M.D., 

PROFESSOR OF HYGIENE IK THE UNIVERSITY OF PENNSYLVANIA, AUXILIARY FACULTY OF 

MEDICINE ; FORMERLY PROFESSOR OF PRACTICE OF MEDICINE IN THE MEDICAL 

DEPARTMENT OF PENNSYLVANIA COLLEGE ; LATELY PHYSICIAN TO THE 

EPISCOPAL HOSPITAL OF PHILADELPHIA | FELLOW OF THE 

COLLEGE OF PHYSICIANS OF PHILADELPHIA ; 

MEMBER OF THE AM. PHILOS. SOCIETY, 

ETC. ETC. 







% 



* °f Wash 



C- PHILADELPHIA: 

HENRY C. LEA. 
1867. 






Entered according to the Act of Congress, in the year 1867, by 

HENRY C. LEA, 

in the Office of the Clerk of the District Court of the United States in and for 
the Eastern District of the State of Pennsylvania. 



PHILADELPHIA: 
COLLINS, PRINTER, 705 JAYNE STREET, 



PREFACE. 



This manual is an unambitious effort to make useful 
the experience of twenty years of private and hospital 
medical practice, with its attendant study and reflection. 
Whatever defects the book may have, the author does 
not concede that it is necessarily a fault that it is small. 
That science whose facts and laws may be stated in the 
fewest words, is the most advanced. Even in the complex 
and still very incomplete science of Medicine, something 
like the same idea may, at least, justify the briefest state- 
ment, compatible with clearness, of its most important 
and best established doctrines and precepts. While 
brevity has been aimed at upon all subjects, the most 
extended consideration has been given to those which 
especially require the attention of the student, from their 
difficulty, comparative novelty, or intrinsic importance. 
In the practical part, however, mere novelty has not been 
made a ground of selection of the means recommended 
for the treatment of disease. Bather than to enumerate 
a long list of remedies which have been proposed or 

1* 



VI PREFACE. 

employed in each case, the author has preferred to give, 
chiefly upon the basis of his own experience, those 
which he believes to be the best. A didactic, almost 
dogmatic method of expression has thus resulted, from 
the effort to condense within the smallest possible limits 
the essentials of Practical Medicine. 

H. H. 

Philadelphia, July, 1867. 



CONTENTS. 



INTRODUCTION ; Systems of Medicine , 



PAGE 
. 13 



PAET I. 
PRINCIPLES OF MEDICINE. 

SECTION I. 
GENERAL PATHOLOGY. 





PAGE 




page 


VIorbid States of the System, 25 


Morbid States of Organs, 


33 


Fever, 


26 


Hypertrophy, 


33 


Toxaemia, 


27 


Atrophy, 


34 


Anaemia, 


29 


Irritation, 


35 


Plethora, 


30 


Inflammation, 


35 


Cachexia, 


30 


Degeneration, 


42 




SECTI 


ON II. 






SEMEK 


)LOGY. 




. Symptomatology, 


47 


Mensuration, 


67 


Digestive System, 


48 


Palpation, Succussion, 


67 


Circulation, 


49 


Spirometry, 


68 


Respiration, 


52 


Percussion, 


68 


Skin, 


53 


Auscultation, 


70 


Secretions, 


54 


Exploration of the Heart, 


75 


Motor Apparatus, 


62 


Exploration of the Abdomen, 77 


Sensory Apparatus, 


63 


Laryngoscopy, 


77 


Psychical Functions, 


65 


Rhinoscopy, 


78 


General Vital Condition, 65 


Temperature in Disease, 


78 


. Physical Diagnosis, 


66 


Inspection of the Dead Body, 


80 


Inspection, 


66 


Medico-Legal Examinations, 


81 



Vlll 



CONTENTS. 



SECTION III. 
GENERAL THERAPEUTICS. 



PAGE 








PAGE 


Classification of Remedies, 83 


Medical Electricity, 




107 


Balancive Measures, 83 


Hot Air Bath, 






109 


Antiphlogistic Treatment, 85 


Inhalation and 


Atomiza- 




Febrifuge Treatment, 93 


tion, 






111 


Supporting Treatment, 94 


Hypodermic Medication, 


114 


Antidotive Treatment, 100 


General Conclusions 


and 




Alterative Treatment, 105 


Maxims, 






117 


SECTION IY. 








NOSOLOGY. 








Classification of Diseases, 118 


Cachexia, 






119 


Phlegmasia, 118 


Neuroses, 






120 


Zymoses, 118 


AtaxisB, 






120 


PAE 


r ii. 









SPECIAL PATHOLOGY AND PRACTICE. 



ECTIONS OF THE RESPIRATORY 




Intercostal Neuralgia, 


139 


System, 


121 


Thoracic Myalgia, 


139 


Pneumonia, 


121 


Phthisis Pulmonalis, 


139 


Pleurisy, 


125 


Affections of the Heart and 




Abscess of the Lung, 


127 


Aorta, 


147 


Gangrene of the Lung, 


128 


Pericarditis, 


147 


Emphysema of the Lung, 


128 


Endocarditis, 


149 


Collapse of the Lung, 


128 


Valvular Disease, 


150 


Bronchitis, 


129 


Dilatation of the Heart, 


151 


Asthma, 


130 


Hypertrophy of the Heart, 


151 


Bronchial Dilatation, 


132 


Fatty Degeneration of the 




Laryngitis, 


133 


Heart, 


152 


Aphonia, 


133 


Sudden Death in Heart- 




Aphasia, 


134 


Disease, 


153 


Laryngismus Stridulus, 


135 


Angina Pectoris, 


153 


Croup, 


135 


Thyro-cardiac Disorder, 


153 


Pleurodynia, 


139 


Palpitation, 


154 



CONTENTS. 



IX 



PAGE 

Cardiac Exhaustion, 154 

Aneurism of Thoracic 

Aorta, 155 

Aneurism of Abdominal 
Aorta, 156 

Affections of the Alimentary 

System, 156 

Stomatitis, 156 

Tonsillitis, 159 

Pharyngitis, 160 

Retro-pharyngeal Abscess, 160 
Stricture of the (Esopha- 
gus, 161 
Gastritis, 161 
Anti-emetic Remedies, 162 
Ulcer of the Stomach, 163 
Cancer of the Stomach, 164 
Cancer of the Bowels, I 64 
Dyspepsia, 164 
Constipation, 167 
Enteritis, 168 
Typhlitis ; Peri-typhlitis, 169 
Peritonitis, 169 
Colic, 171 
Obstruction of the Bowels, 175 
Common Remedies in 

Colic, 176 

Cholera Morbus, 176 

Diarrhoea, 177 

Cholera Infantum, 179 

Dysentery, 180 

Haemorrhoids, 182 

Fissure of the Anus, 185 

Prolapsus Ani, 186 

Affections of the Livee, 186 

Acute Congestion, 186 

Chronic Congestion, 186 

Hepatitis, 187 

Abscess of the Liver, 187 

Jaundice, 188 

Acute Yellow Atrophy, 190 
Pigment Liver, 191 

Cirrhosis, - 191 



PAGE 

Fatty Liver, 192 
Waxy Liver, 193 
Syphilitic Liver, 193 
Cancer of the Liver, 194 
Hydatids of the Liver, 194 
Tubercle of the Liver, 195 % 
Dilatation of the Gall- 
Bladder, 195 
Affections of the Spleen, 195 
Affections of the Kidneys and 

Bladder, 196 

ftenal Congestion, 196 

Uraemia, 196 

Nephritis, 197 

Bright's Disease, 197 

Lithiasis, 200 

Diabetes Insipidus, 201 

Diabetes Mellitus, 202 

Hydronephrosis, 204 

Pyonephrosis, 204 

Cancer of the Kidney, 205 

Tubercle of the Kidney, 205 

Hydatids of the Kidney, 206 

Cystitis, 207 

Retention of Urine, 208 

Enuresis, 208 
Affections of the Brain and 

Nervous System, 209 
Inflammation of the Brain, 209 

Hydrocephalus, 212 

Ramollissement, 213 

Spinal Meningitis, 213 

Softening of the Cord, 214 

Spinal Irritation, 215 

Ophthalmia, 215 

Otitis, 218 

Heat-stroke, 219 

Insomnia, 220 

Night-terrors, 221 

Apoplexy, 223 

Paralysis, 224 

Epilepsy, 230 

Catalepsy, 232 



X CONTENTS. 






PAGE 




PAGE 


Convulsions, 


232 


Prophylaxis of Malarial 




Chorea, 


234 


Fever, 


278 


Tetanus, 


235 


Typho-Malarial Fever, 


279 


Hydrophobia, 


236 


Yellow Fever, 


280 


Hysteria, 


237 


Relapsing Fever, 


284 


Neuralgia, 


238 


Cerebro-Spinal Fever, 


284 


Delirium Tremens, 


239 


Typhus Fever, 


287 


Methomania, 


240 


Typhoid Fever, 


290 


Insanity, 


241 


Plague, 


295 


Hemorrhages, 


242. 


Erysipelas, ^ 


296 


Hemorrhage from the 




Puerperal Fever, 


297 


Mouth, 


243 


Cholera, 


299 


Haemoptysis, 


243 


Rheumatism, 


315 


Pulmonary Apoplexy, 


244 


Gout, 


318 


Haemateinesis, 


245 


Scurvy, 


320 


Hematuria, 


245 


Scorbutic Dysentery, 


321 


Hemorrhage from the 




Syphilis, 


322 


Bowels, 


245 


Syphilization, 


324 


Vicarious Hemorrhage, 


246 


Gonorrhoea, 


324 


Uterine Hemorrhage, 


246 


Cachectic Diseases, 


326 


Dropsical Affections, 


246 


Scrofula, 


326 


Acute General Dropsy, 


247 


Spinal Caries, 


327 


Ascites, 


247 


Coxalgia, 


328 


Ovarian Dropsy, 


247 


Anaemia, 


329 


Zymotic Diseases, 


249 


Chlorosis, 


330 


Variola, 


249 


Beri-beri, 


330 


Varioloid, 


251 


Leucocythaemia, 


331 


Vaccination, 


251 


Pyaemia ; Septicaemia, 


332 


Varicella, 


253 


Embolism ; Phlebitis, 


333 


Scarlatina, 


254 


Angeioleucitis, 


333 


Measles, 


256 


Whitlow, 


334 


Hybrid of Scarlatina and 




Onychia and Onyxis, 


334 


Measles, 


257 


Carbuncle, 


335 


Mumps, 


258 


Addison's Disease, 


335 


Hooping- Cough, 


258 


Goitre, 


336 


Diphtheria, 


260 


Diseases of the Skin, 


337 


Glanders, 


264 


Exanthemata, 


337 


Influenza, 


264 


Papulae, 


338 


Dengue, 


265 


Vesiculae, 


339 


Malarial Fever, 


266 


Bullae, 


341 


Intermittent, 


266 


Pustulae, 


341 


Remittent, 


270 


Squamae, 


342 


Pernicious Fever, 


276 


Maculae, 


344 





CONTENTS. 


xi 




PAGE 




PAGE 


Hypertrophic, 


344 


Menorrhagia, 


357 


Tubercula, 


346 


Leucorrhoea, 


357 


Haemorrhagiae, 


348 


Spermatorrhoea, 


35 S 


Neuroses, 


349 


Entozoa ; "Worms, 


360 


Parasitic se, 


350 


Epizoa, 


365 


Syphiiida, 


351 


Poisons ; bites of serpents 


, 365 


Poison- Vine Eruption, 


354 


Asphyxia, 


367 


Chilblains, 


354 


Foruul^:, 


368 


Burns and Scalds, 


354 


Medicines referred to, 


369 


Miscellaneous Affections, 


355 


Miscellaneous, 


392 


Amenorrhea, 


355 


Aliments, 


397 


Dysmenorrhea, 


356 


Disinfectants, 


400 


Index of Diseases and Formula . 


. 


401 


General Index 


. 





403 



PRINCIPLES AND PRACTICE 



OP 



MEDICINE 



INTRODUCTION. 

SYSTEMS OF MEDICINE. 

Before Lord Bacon, and before, in fact, all others whose writings 
have come down to us, Da Vinci, the architect, painter, and engineer, 
proclaimed in the first half of the sixteenth century, that in the study 
of natural truth we must consult experience, experience rather than 
reason. " Those," said he, " who in the study of the sciences do not 
consult nature, but authors, are not the children of nature, they are 
only her grandchildren.' 7 " Nature begins from the reason and ends 
in experience, but we must take the reverse course, begin from the 
experiment and try to discover the reason." " Theory is the general, 
but experiments are the soldiers, 11 

Not that these were the first utterances in all time in favor of the 
value of observation and experiment in acquiring a knowledge of 
nature ; but only that now, for the first time, these began to be the 
governing ideas of science and philosophy. Aristotle was a natu- 
ralist, although still more emphatically a dialectician ; Leucippus and 
Democritus founded a school whose dependence was almost exclu- 
sively on the evidence of the senses ; and even Cicero, who paid little 
attention to natural science, wrote this wise sentence ; " Praestat na- 
turae voce doceri, quam ingenio suo sapere." But it is especially inte- 
resting to us to recall the fact that most clearly, perhaps, of all the 
ancients, was this reliance upon nature enunciated, and most practi- 
cally was it exemplified, by Hippocrates of Cos. He asserted again 
and again in his works that " nothing should be affirmed concerning 
the nature of man, until after having acquired a certainty of it by the 
aid of the senses." And, although this may seem very obvious indeed 
to us, yet it is a familiar fact that the great intellects of antiquity, 
from the sages of the Vedas and from Pythagoras and Plato, down- 
ward, had more confidence in the truth-compelling powers of their 
own reason ; and even Hippocrates himself often forgot his own max- 
ims, and became dogmatic beyond his knowledge. 
2 



14 INTRODUCTION. 

It is not my purpose here to go into any historical discussion of philo- 
sophy ; which would be inappropriate in this place. Nor will I attempt 
to crowd into a few pages the history of medicine itself. But it ap- 
pears to me that I cannot better occupy space, in this introduction, 
than by endeavoring to place before the mind such a succinct view of 
the most essential phases and mutations of medical opinion, in times 
past and present, as will enable us to apprehend all that bears upon 
the aspects and prospects of the theory and practice of Medicine. 

In the midst of the multitude of authors who have written upon 
medicine, in every age which has possessed a literature, the number 
of cardinal ideas, of distinctive methods, opinions, or principles, has 
not been great. Those who may be considered to have been original 
thinkers or leaders in medical philosophy have been few ; or, if we 
cannot refuse to a larger number the credit of originality, yet that of 
actual novelty is not often theirs, as they have merely started anew 
an idea, a principle, a system, or theory, which had long ago had its 
propounders, its advocates, and its opposers, although it may have 
been again forgotten. 

Yet, few as these essential ideas have been, it will be impossible to 
do more than mention them, as it were, in catalogue, at present. 

A work, for example, might be, and more than once has been, writ- 
ten upon the doctrines of Hippocrates, and of the writings classed 
under his name alone. Suffice it for us to recollect, that the leading 
idea of this greatest of physicians was reliance upon, and observation 
and imitation of nature. Yet he theorized upon health and disease, 
upon the four elements and the four humors, and his system has, there- 
fore, been styled Dogmatic. To him, also, is traced the principle of 
medication by contraries ; TU hwtva, tup hv<xvtu#v iaiiiv iyj^ia'ta. The 
greatest value of the Hippocratic writings undoubtedly consists in 
their numerous and admirable descriptions of the symptoms of disease, 
and of the relations of symptoms to prognosis. The study of hygi- 
enic laws and influences also received from his school much attention. 

Contrasted with the Hippocratic reflective or dogmatic method of 
studying nature, was the more detailed and less systematic plan of the 
contemporaneous Cnidian school. 

Later, with Philinus and Serapion of Alexandria, the distinctly 
Empirical method was promulgated ; in which observation, and this 
alone, especially as to the use of remedies, was urged. No reasoning 
about why or how, but only what, engaged the minds of these indus- 
trious men ; whose materials thus accumulated only too fast for their 
limited powers of classification. Their most elegant writer was Are- 
taeus ; who is not always credited to them ; but whose descriptions of 
disease have seldom been equalled, even down to our own day. 

It is less easy to characterize, in a few words, the school curiously 
called Methodist ; which originated with the opinions of Cleophantus 
of Alexandria, and of Asclepiades the Bithynian, the friend of Cicero, 
and was established by Themison, their disciple, at Rome. Dismiss- 
ing the expectant study of the course of diseases inculcated by Hip- 
pocrates — which they laughed at, as a " meditation upon death" — and 
denying his theory of " coction" and " crises," they dogmatized in a 
different way, upon the changes occurring under disease in the condi- 
tion of the solid structures of the body, and in the movement of its 



SYSTEMS OF MEDICINE. 15 

atomic components. Making but two essentially different patholo- 
gical states, the " laxum" and the ; * striatum, " they simplify the theory 
of medicine very much. Chiefly, however, was Asclepiades distin- 
guished for the moderation of his practice ; rejecting complex, violent, 
and perturbatory remedies, and aiming, as he said, to cure " tuto, cito, 
et jucunde." A somewhat complicated course of alterative treatment 
is, however, ascribed to his successors, by Ccelius Aurelianus, under 
the name of the " metasyncritic circle." 

The most judicious, as well as one of the most learned of physi- 
cians, was Aulus Cornelius Celsus. He selected, from the opinions 
and practice of his predecessors and contemporaries, those of the 
greatest soundness ; so that, not having propounded any exclusive 
dogma, nor yet being limited by the narrow results of observation 
alone, he may be justly styled eclectic ; or, as that term has been made 
odious of late by the usurpation of a set of pretenders, episynthetic, 
or comprehensive, might be a preferable title. 

Galen, less carefully selective, although undoubtedly an admirable 
man. excellent practitioner, and learned writer, renewed and added 
further strength to the hypothetical as well as the practical views of 
Hippocrates. 

From his time, but little of original force appeared in medical 
literature, until after the period of eight or nine centuries of mediaeval 
darkness had been broken in upon by the revival of learning and 
intellectual activity, in the fifteenth and sixteenth centuries. 

In this revival, it was natural that much recourse should be. at 
first, had to the treasures of the ancients. Plato and Aristotle 
divided the newly-revisited realm of philosophy; while Galen, as the 
exponent of Hippocratic doctrine, almost monopolized that of medi- 
cine — until Da Vinci. Telesius, Caesalpinus. Campanella, and Bar-on 
established the inductive method of observation and experiment, 
most obviously necessary for advancement in the physical sciences. 
of which medicine is one; one, too. which, as Lord Bacon expressed 
it. had been previously '-more labored than advanced." 

Chemistry \ which had already received much attention from the 
Arabians, and which, under the fascination of alchemy, had reached 
valuable discoveries — which, in fact, in the hands of Albertus Mag- 
nus. Roger Bacon. Basil Valentin, Isaac Hollandus. and others, had 
performed wonders: and. in the trumpetings of Paracelsus, the arch- 
quack, had made still more extraordinary pretensions — chemistry 
was now ripening into a great science. In the seventeenth century, 
its influence upon physiological and pathological theory much in- 
creased ; and the practice of medicine could not fail to be conse- 
quently affected. By Sylvius of Amsterdam and Leyden, and by 
Thomas Willis especially, a school of Chemzater, iatro-chemists, or 
chemical physicians was instituted. 

Following the discovery by Harvey of the circulation of the blood, 
in the investigations of Sanctorius and Borelli. of Pisa, mech a nics 
likewise found a place in the study of the functions of the body, in 
health and disease. An Iatro-mechaniccd school may be thus said 
to have existed, to which the distinguished Senac, physician to 
Louis XIV., among others, contributed, in a work of great ability. 



16 INTRODUCTION. 

Boerhaave, professor at Leyden, endeavored to combine these, the 
chemical and mechanical modes of studying the body and its dis- 
orders, into an ingenious but complex eclectic system of his own; 
which his influence, as a man of genius, and one of the first of modern 
clinical lecturers, enabled him to extend far and wide. It was rather 
a dogmatical than an empirical eclecticism. 

The latter was admirably exemplified in the writings of Sydenham ; 
who has been well called the modern Hippocrates. Certainly there 
was a great resemblance between the methods of the Greek and the 
English fathers of medicine. 

At the beginning of the seventeenth century, there grew up, in the 
University of Halle, two opposing theories : the Animism or psycho- 
vitalism of Stahl, and the SolidismvLnd neuro-pathology of Hoffmann. 
Stahl's doctrine was, in brief, that the soul of man governs health 
and disease. An expectant or do-nothing practice naturally followed 
from such a view. Hoffmann taught a less simple scheme; but that 
part of it which seemed to the renowned and learned Cullen, the 
nosologist of Edinburgh, to be the most worthy of adoption, was his 
appreciation of the importance of the nervous system in the produc- 
tion of the phenomena of disease. 

But the most brilliant of the meteors that have crossed the horizon 
of medical science, not disappearing, indeed, any of them, without 
leaving some solid precipitate of knowledge, was the Sthenic system 
of John Brown, of Edinburgh; the pupil, friend, rival, and enemy of 
Cullen. 

All life, according to this bold and able, although too reckless 
dogmatist, depends upon stimulation ; all disease upon too much or 
too little excitement, causing direct or indirect debility. Ninety- 
seven cases of sickness out of a hundred, in his therapeutics, require 
stimulation for their relief or cure. Wonderfully simple, this ! 
Haller's doctrine of the irritability of organic tissues was, very possi- 
bly, its source ; but so nearly akin was it to the great idea of vitalism, 
dimly seen by Pythagoras, announced by Hippocrates, but lost for 
ages until revived and distorted by Yan Helmont and Stahl, and 
afterwards rendered more positive by J. Hunter and Bichat, — so near 
was it to this imperishable idea, that Brown's theory, thus supported 
at once by ancient philosophy and modern discovery, had an unpre- 
cedented influence upon medicine. All theories and theorists, during 
and since his time, unless we except the discreet vitalism of Barthez, 
of Montpelier, have reflected or refracted, with various modifications, 
the Brunonian ray. 

What have we had since, in fact ? Easori, in Italy, adopted 
Brown's physiological basis, but considered that excitability and 
excitement were multiple, and unequally distributed, in disordered 
states, in different organs ; and, moreover, that over-excitement was 
much more frequent and demanded more attention in practice than 
Brown had supposed. Hence arose his sedative or " contro-stimu- 
lant" method, by large bleeding and tartar emetic ; so famous once, 
especially in the treatment of inflammatory affections of the chest. 

Broussais, in France, proceeding upon the same original basis, saw 
in local irritation and inflammation, mostly of the alimentary canal, 
the seat and centre, the fons et origo of the dynamic or excitational 



SYSTEMS OF MEDICINE. 17 

error which caused all diseases. His practice varied from both Brown 
and Rasori ; his whole object being to calm and allay the central irri- 
tation by diluents, demulcents, local depletion, and counter-irritation, 
avoiding all heroic treatment. 

In this country, which can hardly be said to have had a system 
before Rush, that noble and independent mind was also influenced 
by the Brunonian radiation ; although a still different view of patho- 
logy and therapeutics resulted from his reflections and observations. 
The "unity of disease" was, with him, a favorite idea. Although 
his strong good sense did not allow this to exclude from his apprecia- 
tion remedies and modes of treatment not easily reconciled with such 
a scheme, Rush evidently leaned much toward the opinion, that all 
acute diseases were but different " states of fever ;" for the mitiga- 
tion of most of which the lancet was the most potent and indispensa- 
ble remedy. In this he resembled Rasori rather than Brown or 
Broussais. Even earlier than the universal dissemination of the 
teachings of the latter, the distinguished successor of Rush. Dr. Na- 
thaniel Chapman, of this city, claimed and afforded evidence that he 
had first taught the theory of the local origin of fever, in irritation 
of the alimentary canal ; but he did not allow it to modify his prac- 
tice in the same manner as Broussais. 

Now. — let us look back. Who have been the larpo-TCpo^tai, the great 
leaders in medical speculation, the reformers and deformers of medi- 
cal practice? The list is not a long one. although its scope of time 
reaches over two thousand years. Permit me to hazard their enume- 
ration. Hippocrates, Serapion, Asclepiades, Celsus. Sylvius, Harvey, 
Borelli, Sydenham, Boerhaave, Stahl, Hoffmann. Haller, Cullen. Aven- 
brugger, Brown, Jenner, Hunter, Bell. Bicbat, Barthez, Pinel, Rasori, 
Rush, Hosack, Laennec. Broussais. Louis, Liebig, Virehow. 

And what have been their essential ideas, stripped of all their com- 
plexities and environments? Naturalism, empiricism, eclecticism, 
humoralism, solidism. chemicism, mechanicism, neuropathology, 
stimulism, phlogisticism, pyrexism, vitalism, and latest, of the pre- 
sent date, cellular pathology. ' I leave out of the list the Thomsonian 
extravaganza of thermalism, and the Hahnemannic homoeopathism, 
as, however serious may have been their detrimental effect upon the 
welfare of the public at large, they have scarcely influenced the pro- 
gress or present status of medical science, either for good or evil. 

By naturalism I mean dependence upon nature, and systematic 
imitation, in practice, of her spontaneous curative processes. We 
have already referred to this as the leading Hippocratic idea. It was 
rejected by the early Methodists, practically repudiated by Cullen, 
and systematically excluded by Rush. Quite recently it has been 
conspicuously illustrated and defended in the lucubrations of Sir 
John Forbes, following those of Dr. Bigelow, of Boston, upon "Na- 
ture and Art in Disease;" to the former of which the soubriquet of 
"Young Physic" has been applied. 

Empiricism is strict adhesion to experience ; the accumulation of 

1 We may add, now, the gn.nglio-tlierapy of Dr. John Chapman ; built upon 
the vivisections of Bernard and Brown-Sequard, and an ephemeral (though 
now current) physiological speculation, in regard to the circulation. 

2* 



18 INTRODUCTION. 

means of treatment simply by observation and experiment, independ- 
ently of physio-pathological reasoning. The most favorable example 
of this among the ancients, was Aretaeus ; of distinguished moderns, 
Sydenham, Laennec, and Louis. 

Eclecticism or episynthetism is, of course, the selection or combination 
of what is deemed best in several methods, as, in practice, of means or 
measures, some of which have been obtained by mere observation, and 
some from physiological reasoning or deduction. Celsus afforded the 
most beautiful early example of this ; it has been exemplified, although 
at the same time, somewhat paradoxically, derided, in our own period, 
by Trousseau, of Paris. 

All of the other systems which I have named are phases of Rational- 
ism, which is the proper antithesis of Empiricism. 

Solidism, first broached perhaps by the ancient school of Asclepi- 
ades, with its laxum and strictum, was urged to its farthest limit in the 
meclianicism of Borelli, and in the neuro-pathology of Hoffmann, Cul- 
len, and Henle. It was taught in this city for twenty-five years by 
Professor Chapman. 

Humoralism, the older view, which saw in changes of the fluids all 
that was essential in disease, pervaded the system of Galen, and the 
Galenists of the fifteenth and sixteenth centuries. The chemicists 
generally have had a natural leaning towards it. In this country it 
was represented at one time by Dr. Hosack, of New York. A very 
distinguished example of it has lately been known and respected in 
England, in the lamented Robert Todd, of London. 

Chemicism was boldly inaugurated by Sylvius De Lebo, in the 
seventeenth century, but has received its ripest contributions in the 
two last decades ; especially from Liebig, of Giessen, and the other 
chemical physiologists, Lehmann, Moleschott, &c. 

Meclianicism, as an exclusive system of physiological or pathologi- 
cal reasoning, was never permanently established ; its influence, as 
affording even a predominant bias, having been always confined to a 
few thinkers during a brief period. 

Neuro-pathology has had a more important place ; dividing with a 
modified humoralism the domain of medical theory, even down to the 
present hour. We can never dismiss the consideration of the nervous 
centres and their communicating nerves, from the study of the human 
functions, healthy or morbid. So that, although it is decidedly an 
error to say, as some do, that man is all brain, or that the " nervous 
mass" is the animal, yet the nervous system must be made prominent 
in all medical inquiries. 

Enough has been said already to explain the nature and powerful 
influence of the Brunonian theory, of excitement, or of sthehia and 
asthenia, which I have named under the title of stimulism. It was 
one step toward the application to pathological and medical truth of 
that dynamic physiology, that study of the forces of the living body, 
in connection with the constantly acting forces of external nature, 
which is now, or soon, destined to rule supremely, not as excluding, 
but as guiding our investigations of the chemical and mechanical 
changes both of the solids and of the fluids. Life is not merely exci- 
tation; but normal excitation is one of the requisite conditions of the 
performance of all the functions of the body, not even excepting that 



SYSTEMS OP MEDICINE. 10 

of growth and development itself; since to this a certain degree of 
heat at least is essential. 

Rasori was, moreover, right in saying that excitement is not a unit 
for the whole body, but may be unequal in its different parts ; and, 
moreover, that excess of excitement of one or more organs or functions, 
is at least as frequently present in acute disease as the reverse. 

So, too, Broussais made a just amendment of the same scheme, to a 
certain extent, in noticing the sympathetic and secondary effects of 
local irritation ; although he, as well as our Chapman, undoubtedly 
exaggerated the relative importance of irritation of the stomach and 
intestinal canal. 

We need not pause for a moment over the Stahlian theory of the 
organic soul or autocrateia ; although very lately a view much like it 
has been again taken, by Laycock and Morell, under the cognomen of 
the "unconscious soul." 

The last phase of revolution in the scientific basis of medical opinion, 
has been that which, in the language of its most eminent leader, Vir- 
chow, of Berlin, we may designate as cellular pathology. Associated 
in similar, although not quite identical views, have been Prof. Bennett, 
of Edinburgh, and the late Dr. Addison, of London. 

It has been a favorite idea with the physiologists of our period, 
that in the general law of organic cell-genesis, in the fact that every 
living being, human, animal, and vegetable, springs from a globoid 
germ-cell, while most of the separate tissues also have the cell for their 
first starting form ; that in this we have the great central radical Fact 
of physio-pathology, out of which (as in physical science out of the 
Newtonian law of gravitation) all truth in the history of the animal 
organization, and thus in medicine, must grow. But Dr. Bennett, 
one of the most earnest students and teachers of the cell doctrine, 1 
denies that to it can be awarded such a place or potency ; as it is not 
a universal law, but has its manifest exceptions. Dr. Beale, also, a 
leading British authority in histology, insists upon some essential 
modification in Yirchow's theory. 

It does not belong to me to discuss this point here; but. as it bears 
largely on the theory of medicine, I will merely say, that if there be 
one fact or idea which more than any other is the gravitative centre 
of all truth in physiology, pathology, and medicine, it is that of the 
peculiarity and supremacy in the body of the life-force, and of its 
intimate relations with the other physical forces ; 2 of its being, in fact, 
capable of degrees of life temperature, like those of heat temperature, 
in the body as a whole, and in its various parts and organs ; of its 
possessing attributes, like the other forces or phases of impetus and 
molecular movement in nature ; which must be much more patiently 
and thoroughly studied than they have yet been, before we can be 
said to understand the human economy, even so well as astronomers 
now do the solar and sidereal systems. 

This brings us towards the conclusion of our inquiry. We have 
been examining, in this brief manner, several schemes of rationalism. 

1 Clinical Medicine, Introductory Lecture. 

- See Grove, Carpenter, and others, on the Correlation of Physical and Vital 
Forces; himan, Foundation for a New Theory and Practice of Medicine; 
Chambers^ Renewal of Life ; &c. 



20 INTRODUCTION. 

But, as the use of facts and ideas in the practice of medicine is our 
stand-point, we must now ask, Is rationalism available for the treat- 
ment of disease? Is physiology perfect? How much of it is positive? 

"We are compelled to answer — Physiology, and with it necessarily 
pathology, is one of the least-matured, because one of the most com- 
plex of the sciences. What would be said, then, were a man to 
undertake to repair a watch, when he had never seen its works in 
motion, and had no proven knowledge of the mode of action of nearly 
all its machinery? If he should find, on trial, that hanging it up, or 
laying it down, or shaking it when it stopped, or keeping it warm or 
cold, promoted its good time-keeping — very well; let him do so. But 
if, in this state of uncertain knowledge, he should seize and alter, with 
fingers or forceps, the delicately arranged and complicated wheels and 
springs, would not the chances be, that he would do more mischief 
than good ? Nor would reasoning about possible or probable watches, 
theories in chronometry, avail him much toward the medication of the 
particular timepiece in his hands. Yet this is our position, as physi- 
cians, regarding the present relation of physiology and pathology, to 
the actual treatment of disease. It seems, therefore, only a slight 
over-statement of Trousseau's, that "La rationalisme ne conduit en 
medecine qu'a des sottises." Rationalism in medicine leads only to 
absurdities. 

We might easily confirm Trousseau by other authorities, early and 
late. Stahl spoke of the materia medica of his time as a "stable full 
of ofifal." Sydenham complained that practice was " pestered with 
too many eminent remedies." It is said, that when Sydenham was 
asked by Sir R. Blackmore, what book to begin his medical studies 
with, he replied, Don Quixote. Bichat denounced the vague theories 
of medication prevalent in his day, and declared that but little was 
really positive in our knowledge of the action of remedies. Pinel had 
so little confidence in therapeutics, that his only study of disease was 
for a naturalistic classification: "Given a certain malady — to find its 
place in the nosological system." Laennec considered physiology and 
pathology "vain amusements of the mind." Says Lebert, "We can- 
not yet, unhappily, construct therapeutics on the basis of scientific 
medicine ; and with the best intentions in the world we can regard the 
greater part of its precepts but as the result of empiricism." 

But, some may exclaim, this is treason ! This would remove the 
practice of medicine from science altogether, and leave it at the mercy 
of Paracelsus, and Cagliostro, and the old women ! Not so. We 
have only to turn back to the grand platform of Bacon, on which all 
modern science is built, to see that to found the practice of medicine 
on observation is to make it eminently scientific. What science can 
do without empirical observation ? Can physics, or astronomy, or 
chemistry? None of them. How irrational, then, to attempt to reason 
out. a priori, therapeutics, or to place it upon any other principal 
basis than clinical observation ! Blind, uninstructed, unsystematic 
empiricism is a bane to society, and a disgrace to the human intellect. 1 

1 I advise no one to imitate the follies of Cato the Censor; who, while he 
forbade his son ever employing a physician, yet dosed his own wife to death; 
attempted to reduce dislocations by repeating magical words, and wrote a book, 
in which he recommended cabbage as a sovereign remedy for many diseases. 



SYSTEMS OF MEDICINE. 21 

But scientific empiricism constitutes the most rational practice attain- 
able, while physiology is imperfect. What is most wanted now. is 
more positivism in medicine ; more exact observation of clinical and 
therapeutical facts. It is otherwise in most of the natural sciences. 
Agassiz, one of the great leaders in science, has remarked, that 
thought and generalization are now especially required amongst natu- 
ralists; who are in danger of being buried among their multitudinous 
detailed facts, as knights of old sometimes were borne down by the 
weight of their owq armor. But it is not so in our science. Medicine 
needs more fact and less theory. I could sustain these positions by 
argument, by citation, and by example ; but we have no room. The 
proposition must be barely stated, that the most complete knowledge 
possible of a disease will never alone inform us, what will be the effect 
upon it of any remedies, until experience has put them to the test. 
The two blades of the scissors of practical medicine are, diagnosis and 
clinical proof. Nor does our total ignorance of the modus operandi 
of any agent in the least interfere with its availability in the treatment 
of disease, when that treatment has been proved to be successful. 
We do not know — nor does the chemist require to know — why sugar 
is sweet, or sulphuric acid sour; or why the latter will redden litmus, 
while an alkali will render turmeric brown. It is no more necessary, 
although it would be interesting, to know how bitters improve the 
appetite, or iodide of potassium cures syphilitic rheumatism. We 
may use opium to produce sleep, or lull pain, although we know little 
more than Moliere's doctor — " opium facit dormire, quia est in eo 
virtus dormitiva." 

It was, in fact, as it was long ago observed, " only after men had 
found remedies, that they commenced to reason upon them." The 
most remarkable treasures of medicine have been discovered almost 
by accident, and have obtained their place in the materia medica 
often against the protests of the theorists. Opium is one of the 
oldest of drugs. 1 Iron is nearly as ancient. Mercury was a contri- 
bution of the alchemists. Arsenic and colchicum appeared first as 
secret remedies. Iodine (in burnt sponge) and sulphur were popular 
and domestic before they were professional medicines. And did not 
the French academy formally denounce tartar emetic ? Did not all 
the schools disbelieve in cinchona, because it neither sweated, puked, 
nor purged ? And Jenner, who drew the idea of vaccination, by a 
most sagacious induction, from a popular tradition of the country, 
against what strong theoretic opposition did his noble discovery 
have to establish itself ! 

Nolens volens, then, we have to acknowledge our indebtedness, in 
therapeutics, to empirical observation. But it is the vocation of the 
true physician to make it scientific. To know that two cases of dis- 
ease are really alike, and not only apparently so, in order to the appli- 
cation to them of the same remedies ; to make accurate comparison 
of the virtues of different modes of treatment, avoiding the " post hoc 
propter hoc" fallacy ; and to appreciate the conditions and circum- 
stances which modify the actions of medicines, as they do the course 
of diseases ; these are tasks which enlist the highest faculties of 
analysis, as well as of observation. 

Pereira. 



22 INTRODUCTION. 

Moreover, medicine is progressive. Even an incompleted physio- 
logy may suggest safe and proper experimentation. And for good 
diagnosis we need pathology; for pathology, physiology is indispen- 
sable. We do not admit, then, with Laennec, that these beautiful 
sciences are but " vain amusements." We look forward to the day, 
when the laborious and intelligent culture they are now receiving, 
will be repaid by a tenfold harvest, practical as well as abstract. 
The time may come, when the why and the how of therapeutics may 
be largely as well as accurately explained. But, practical medicine, 
having its crying necessities, cannot wait for such an era; let it use 
its facts, and not be misled by false expectations. 1 

Yet, we must remember, that it is the facts, not of the experience 
of an individual, which most of all is " experientia fallax," but of the 
aggregate experience of the whole profession, in all time, that consti- 
tute the body of therapeutical science; which should, as Dr. Todd 
has said of pathology, be reviewed and reconsidered from time to 
time ; but which can never be abandoned or rejected. It is not well, 
then, to call the great physicians, our predecessors, as Dr. Bennett 
has done, " blind guides." Bather, may we, with the late Dr. Alison, 
believe that a disagreement between a newly-broached pathology and 
the practical experience of all time, is a much better reason for set- 
ting aside the new pathology than the old practice. 

We may now sum up the substance of the foregoing remarks, by 
asserting that the therapeutical methods or principles upon which we 
may deal with the treatment of disease are essentially three ; 2 the 
natural, hygienic, or expectant, the specific or purely empirical (in- 
cluding the tentative), and the analytical or conditional (including the 
perturbative or alterative). Of the first two quite enough has been 
said. Of the last it will suffice to say that it is the most of all open 
to suggestion from positive physiology and enlightened pathology. It 
comprises the rational treatment of diseased conditions of the body, 
for which no direct or specific remedy has been discovered ; a part of 
medicine of very great importance, but in which the greatest varia- 
tion has necessarily occurred in the past, and continues yet to exist. 
This is the debatable ground, upon which tournament upon tourna- 
ment and crusade after crusade have been fought; the world at large 
looking on sometimes with more amusement than profit. The lesson 
of these petty wars, however, — pre-indicated clearly by the old clas- 
sical writers upon medicine, — has been at last tolerably well learned : 
Not to do harm when we are unable to do good; the reversal of the 
old maxim, " melius anceps quam nullum remedium ; because, in the 
restoration of a patient from disease, the physician is not the only nor 
even the stronger agent, nature being the principal, he only the acces- 
sory. 3 Some have given credit for this medical gospel to distinguished 
recent writers, as Dr. Bigelow and Sir John Forbes ; but they are 
revivers of the doctrine only, not its discoverers. Hippocrates dis- 

1 i( When there is no certain knowledge of a thing, a mere opinion about it 
cannot discover a sure remedy." il Medicine ought to be rational ; but to 
draw its methods from the evident causes ; all the obscure being removed, not 
from the attention of the artist, but from the practice of the art.'''' — Celsus, 
Treatise on Medicine. 

2 Lordat. See Renouard's Hist, of Medicine. 3 Chomel. 



SYSTEMS OF MEDICINE. 23 

tinctly recognized the self-limitation of many diseases. Ta xpwouno. 
xojl fa xsxpLjjLeva dpruo£ \ir { xlvszlv firfis i'tu>Tzp07tou8 iv. fxr t tE rpapuaxzir^i, (xrr 1 
ataouw iptOus/ioufi*, fax' lar. 1 So also did Asclepiades. notwithstanding 
the protest of his sect against Hippocratism ; when he said, that the 
best cure for a fever is the fever itself. 2 So did Sydenham 3 and others 
who wrote long ago. 

And now, although Dr. Bennett, of Edinburgh, predicts the u ap- 
proaching downfall of empirical practice." yet his late co-laborer. Dr. 
Todd, of London, urged in his last words the importance of its sup- 
port in its clinical research ; and the philosophic medical historian, 
Kenouard, seconding the efforts of Louis, the founder of the numeri- 
cal method, foretells the coming triumph of rational empiricism or 
inductive medicine. We may well believe that this prophecy will 
yet be fulfilled. 

1 Aphorism 20, Section 1st. 3 Caelius Aurelianus. 

3 M To imagine that nature always needs the aid of art is an error, and an 
unlearned error too." 



PART I. 

PRINCIPLES OF MEDICINE. 



SECTION I. 

GENERAL PATHOLOGY. 

Disease may be defined as a perversion either of the functions or 
of the structure of the body or of any of its parts. It is, in other 
words, a deviation from the normal physiological state or action of 
the organism, under the disturbing influence of morbid causes. 
The seat of disease may be 

In the constitution : e. g. secondary syphilis ; tuberculosis. 
In special tissues : e. g. mollities ossium. 
In particular apparatus: e. g., dyspepsia; hysteria. 
In individual organs : e. g. pneumonia; cirrhosis; hydatids. 
In the blood: e. g. anaemia ; scorbutus ; typhus. 
■ Of course, disease may be, and generally is, not limited to what is 
to be regarded as its principal or original seat. For example, in 
cholera, while its cause, no doubt, acts first upon the blood, the gan- 
glionic system is also affected, as well as the stomach and bowels, &c. 
Morbid states of the system : — 
Fever ; 
Toxaemia; 
Anaemia ; 
Plethora ; 

Degeneration of organic force (Cachexia) ; 
Depression; 
Exhaustion. 
Morbid states of organs : — 
Hyperaemia ; 
Hypertrophy ; 
Irritation ; 
Inflammation ; 

Hyperaemaesthesia, or " chronic inflammation ;" 
Atony ; Exhaustion ; 
Atrophy ; 
Degeneration. 
Of the above, the most important general or systemic morbid states 
may be included under fever, toxaemia, and cachexia ; constituting 
a sort of " tripod" of systemic disease. 
3 



V' 



26 GENERAL PATHOLOGY. 

A similar tripod of the most frequent and important local disor- 
ders may be established, of irritation, inflammation, and atrophy. 



GENERAL PATHOLOGY OF AFFECTIONS OF THE SYSTEM. 

FEVER. 

In using the term fever, as applied to a morbid state of the system, 
we must remember that the same word is also used as a part of the 
designation of several' complex diseases : as typhus fever, yellow fever, 
remittent fever, etc. This double use of the word is unfortunate, but 
cannot now be avoided. 

Symptoms of Fever. — Increased heat of the whole body ; 

Dryness of the skin, mouth, etc.; 

Diminution in bulk of the excretions ; 

Muscular debility ; 

Frequency of the pulse ; 

Functional disturbance of stomach, brain, etc. 

Heat is the most essential characteristic of the febrile state, having 
given name to it in all languages. 

Notwithstanding the scantiness in quantity of the stools, urine, 
and perspiration in fever, it has been shown by Yirchow, Vogel, 
Bocker, Parkes, Jenner, and Hammond, that the actual amount of 
solid matter excreted, especially by the kidneys, is generally increased. 
Although none of these observers have made chemical examination of 
the expired air during fever, we have, in the heavy, offensive odor of 
the breath, evidence that it, too, contains an excessive amount of de- 
composing organic material. It is highly probable, also, that much 
excrementitious matter is, during fever, retained in the blood. It has 
been observed that if a local inflammation, as pneumonia, occurs 
during the febrile attack, the excess of excreted solids (urea, etc.) dis- 
appears until the inflammation has passed. 

This increase of the disintegration of the substance of the body 
(tissue-metamorphosis) is, at present, one of the most prominent and 
interesting phenomena connected with the pathology of fever. The 
whole subject, however, is surrounded by obscurity, notwithstanding 
the fact that the symptoms and aspects of the febrile state have been 
familiar ever since man became a prey to disease. 

On the basis of the facts observed and scrutinized at the present 
time, I think we may venture to throw out a comprehensive theory 
of fever. Thus, — its essential phenomenon is increased heat of the 
body ; this being produced by excessive tissue-metamor gliosis, under 
an abnormal "tension-condition" (Yirchow) of the ganglionic nerve- 
centres; which abnormal condition is the result of (Addison) either 
1, corpuscular toxaemia, or 2, plasmic toxaemia, or 3, (Campbell & 
Mailer) sympathetic irritation from local inflammation. 

A pathological classification of fevers, convenient for some pur- 
poses, is, into irritative, reactive, and toxsemic fevers. 



TOXEMIA. 2t 



TOXEMIA. 



Toxaemia, more properly toxicohasmia, (from to^cxov, poison, and 
cuua, blood), is a term used to indicate poisoning of the blood. 

After all the long and reiterated disputes between the advocates of 
the exclusive solidist and humoral pathologies, it has now become a 
matter of general recognition that both the fluids and the solids are 
involved ra almost every disease, — their mutual interdependence 
making the contrary impossible. 

Certain diseases, however, more than others, are believed, upon the 
strongest evidence, to depend upon a chemical and dynamic change in 
the blood, to which the name of toxaemia is applied. 

Toxaemia may originate : — 1. By the introduction into the blood of 
morbid poisons from without ; as in syphilis, smallpox, remittent 
fever, &c. 2. By morbid alteration from processes occurring in the 
blood itself. 3. By absorption of poisonous material, by the vessels, 
from diseased parts of the body ; as in purulent infection after wounds, 
&c. 4. By the non-excretion, and consequent accumulation in the 
blood, of post-organic or excrementitious substances, which, by their 
own properties, or by the chemical changes they undergo, prove in- 
jurious to the system. Obstructive jaundice, and uraemia, afford the 
best examples of this last occurrence. 

1. All of the zymotic diseases (e. g., exanthemata, yellow fever, 
diphtheria) have their origin explained by the first of the above modes 
of blood-poisoning. 

Yet, our knowledge of the very existence of several of these " morbid 
poisons" is inferential only. Our idea of their nature is conjectural ; 
and our reasonings upon their mode of action upon the blood and 
system at large are entirely speculative. 

Some facts, however (see Simon's Lectures on Pathology), are well 
deserving of notice. 

1. The effects of these poisons, when introduced into the body, are, 
both local and constitutional symptoms. The constitutional symp- 
toms, which begin the attack, are nearly alike for them all ; — the local 
symptoms are peculiar for each one. 

2. The smallpox virus is the most readily studied of all of these 
causes. This material is evidently volatile, as it acts often through 
considerable distances ; and it is soluble, because it infects, sometimes, 
the foetus in utero, which has no communication of fluids with the 
mother, except by placental endosmosis. The poison of primary 
syphilis is not thus transmissible, although it is directly contagious 
by inoculation ; that of secondary syphilis is not 1 contagious, but is 
transmissible by descent. 

3. One attack of smallpox, scarlatina, measles, hooping-cough, usu- 
ally gives immunity for the rest of a lifetime. It may, from this, be 
argued, that besides the materies morbi or causative matter, another 
material must exist in the blood of the susceptible person, which com- 
bines with the former (thus producing the disease), and which is ex- 

1 Recent experiments have occasioned some doubt as to the entire correct 
ness of this commonly accepted statement. 



28 GENERAL PATHOLOGY. 

haustible, 1 (Illustration : the saturation of a carbonated alkali by an 
acid ; after a certain portion of the latter has been added, it will cease 
to effervesce with any subsequent addition of the same.) 

Vaccination can be best explained upon this view. Just as more 
than one acid will neutralize potassa or soda, etc., so that after it has 
been saturated with sulphuric acid it will not react with nitric — so the 
virus of the vaccine disease appears capable of saturating and ex- 
hausting that material in the body, the presence of which constitutes 
the susceptibility to variola. 

No such immunity after a single attack is found to exist in the case 
of the miasmatic fevers (remittent, intermittent). The element in the 
blood for which their morbid poison has affinity is, therefore, not ex- 
haustible. Several reasons exist for conjecturing this element to be the 
red corpuscles themselves. 

Of the different hypotheses propounded in regard to the modus 
operandi of zymotic (epidemic, endemic, infectious, or contagious) 
causes upon the blood, that which has best stood its ground is that of 
catalysis, or continuous molecular action. 

Liebig first urged this theory, upon the analogy between the action 
of yeast in producing fermentation, and that of a virus, as of smallpox, 
in producing its effects upon the system, through the blood. It is true, 
that the blood does not ferment ; the action is therefore not similar, 
but analogous. Chemical action, of a certain kind, going on in the 
particles of the yeast, or of a virus, is, by their contact with another 
substance, communicated to or instigated among the particles of the 
latter. A mechanical analogy to illustrate this, is the setting in 
motion of one cog-wheel by another. A physical illustration, less re- 
mote, is that of the extension of fire from a burning body to other 
combustibles near it. 

2. Toxaemia from spontaneous changes in the blood itself under 
causes or conditions which do not affect the solid structures of the 
body, if it occur, must be rare. Heat-stroke may be an example ; that 
is, the dangerous or fatal effect of extreme heat, with exhaustion, away 
from the direct influence of the rays of the sun. Here the blood 
probably undergoes a chemical change which renders it unfit to neu- 
tralize the nerve-centres and other organs. 

Perhaps pyaemia, ichoraemia, or septaemia (pus-forming blood, — 
contaminated blood, — blood-decomposition), as nearly the same affec- 
tion is called by different authors, may be supposed to occur some- 
times spontaneously. More often, however, such an affection is 
ascribed to the next mode of causation. 

3. Absorption of deleterious material, by the bloodvessels or lym- 
phatics, from parts of the body at the time in a state of disease, may 
cause purulent infection, or pyaemia. 

Absorption of pus (containing pus-cells) cannot occur without a 
solution of continuity in the vessels ; the -pus-cells cannot go through 
their walls. But in arteritis or phlebitis, suppuration of the artery 
or the vein may introduce pus into the blood. 

1 Reflection will show that there is no real incompatibility between this 
theory and that of zymosis, to be mentioned presently. We have not space, 
however, for the farther discussion of so speculative a subject. 



ANJEMIA. 29 

In the greater number of cases, it is not pus, but an unhealthy 
material ©f a less definite nature, which contaminates the blood by its 
absorption. This may take place after wounds or surgical opera- 
tions, — from the womb in the puerperal state, <fcc. Pyaemia is 
attended by great prostration, rapid pulse, copious perspirations, 
low delirium, and the depositing of pus and formation of abscesses in 
different parts of the body. It often begins with a chill. 

4. Toxaemia from non-elimination of the secretions may follow, of 
course, upon prolonged constipation, obstruction of the biliary duct, 
inaction of the liver, or suppression of the action of the kidneys. 

Effort is made (according to the adaptations of nature), when one 
emunctory fails to act. to carry out its excreta by other channels. 
Especially the skin aud kidneys act thus vicariously for each other. 

AVhen the blood is in no way rid of those effete particles which 
should make the solids of the urine, the resulting condition is called 
uraemia. Its symptoms are, pain in the head, dulness of sight and 
hearing, vertigo, nausea and vomiting ; ending, unless relieved, in 
convulsions, coma, and death. Pregnant, women sometimes have 
urcemic convulsions (G. Braun), from foetal pressure obstructing the 
renal circulation. 

The term cholaemia is less used, though quite as justifiable as 
uraemia. It means, retention in the blood of the excrementitious 
matter of the bile, from inaction of the liver. Cholesteraemia is a 
term preferred by Dr. A. Flint, Jr., who asserts cholesterin to be the 
excretory ingredient of bile. 

Jaundice is well known to be of two origins : 1. obstruction of 
the biliary ducts, with reabsorption of bile into the blood ; 2. suppres- 
sion of the secretion of the liver. (A third is possible, — perhaps 
present in the jaundice of infancy; viz., excessive formation of yel- 
low pigment in the blood, and its deposit in the skin, &c., without 
disorder of the liver.) 

In jaundice from obstruction and reabsorption, the symptoms are 
milder and the state less dangerous than in that from suppression of 
the action of the liver. Severe, and even fatal disease of the liver 
may occur, however, without jaundice. 

Dr. Harley has shown that the diagnosis between these two forms 
of jaundice may be made, on analysis of the urine, by finding the 
coloring matter of the bile always in the urine in both, but the biliary 
acids only in the obstructive form. 

Slight and transient cholaemia is, no doubt, common. Although 
the term i; biliousness" is much abused, it is not always quite a mis- 
nomer. As signs of the condition mentioned, we find nausea, bitter 
taste in the mouth, constipation and dizziness, with yellowness of 
the tongue, conjunctiva and skin. 

ANEMIA. 

Anaemia [spancemia, hydrcemia) is the common term indicating- 
poverty of the blood. The density of that liquid is diminished, and 
there is a deficiency in the number of the red corpuscles. Exhaust- 
ing hemorrhages or discharges, severe attacks or long continuance of 
disease, insufficiency of food, &c, may cause this condition. 

o 



30 GENERAL PATHOLOGY. 

It is shown by paleness (sometimes with occasional flushes) of the 
face, even of the lips, and tongue, as well as of the hands ; debility ; 
feebleness and excitability of the pulse ; frequently, palpitation of the 
heart, and a belloivs murmur, audible especially near the base of the 
heart, to be carefully distinguished from valvular murmurs of organic 
disease. Nervousness, and neuralgic pains, are also very common in 
the anaemic. 

Chlorosis, although by some separated from anaemia, is generally 
regarded as a variety of it, occurring in young females. The name 
is given on account of the peculiar sallowness of the complexion. 
Perverted appetite, as for charcoal, slate-pencils, &c, is one of its 
occasional symptoms. 

Morbus Addisonii, Addison's disease, is a rare constitutional 
malady, in which anaemia coincides with bronzing of the skin, disease 
of the supra-renal capsules, and progressive debility, usually ending 
in death. The capsular disease is not shown by any definite local 
symptoms during life ; and its connection with the cachexia has not 
been explained. 

Leucocythaemia (leukaemia) has been, after Yirchow and Bennett, 
recognized as a condition in which the number of colorless corpuscles 
in the blood is increased ; sometimes numbering one to four, three 
or two, instead of one to fifty (normal) of the red corpuscles. This, 
of course, can be only ascertained by means of the microscope. 

Enlargement of the liver, and still more of the spleen, and disease 
of these organs as well as of the thyroid and lymphatic glands, are 
found to attend this order. It most frequently affects men. Its 
symptoms are, pallor, emaciation, diarrhoea, epistaxis (bleeding from 
the nose), or other hemorrhages, and dropsy. 

Melanaemia is the name given (Frerichs) to a state of the blood 
most common in severe malarial fevers, in which the coloring matter 
(pigment) escapes from the corpuscles, and is deposited in the liver 
and other organs. 

Plethora involves an excess in the density of the blood, and in the 
number of its red corpuscles ; the opposite to anaemia. It is shown 
by a high color, distension of the bloodvessels, a full, strong, but 
rather slow pulse, and general roundness of the figure. It may exist 
without actual deviation from health ; but the plethoric are especially 
liable to acute inflammations, active congestions, and hemorrhages. 

CACHEXIA. 

Cachexia (from zazoj, bad, and e$c$, habit), is usually understood to 
mean a depraved habit of system ; an error of development and nutri- 
tion, affecting the general state of the blood and organs with per- 
version. 

There is, at the same time, no good reason why we should not 
speak of local as well as general cachexias ; although this has not 
been usual. 

Addison's disease, and leucocythaemia, may be regarded as ca- 
chexiae. Much more frequent, and therefore important, — the most 
common and destructive of all cachectic affections, is tuberculosis. 



CACHEXIA. 31 

While diverse opinions exist as to the essential nature of tubercle, 
and its origin, there is a general agreement among pathologists and 
clinical observers, upon most of the following points. 

1. Tuberculosis and Scrofulosis are identical. 1 The term scrofula 
is generally applied to certain slow inflammations, abscesses, ulcera- 
tions, and other disorders of the skin, mucous membrane, glands, and 
bones, which occur especially in young persons, and are characterized 
by the moderate degree of vascular excitement attending them, with 
the great obstinacy or chronicity of their career. In many cases, also, 
of external scrofula, particularly in the glands, a deposit of curd-like 
or cheesy material is found, not distinguishable from tubercle. 

2. Of the causes apparently connected with the production of the 
tubercular or scrofulous diathesis (to which the general name tubercu- 
losis may be applied), the most obvious and constant is hereditary 
predisposition. 

3. This diathesis may, however, undoubtedly be acquired without 
inheritance. Change of climate, from a warm to a cold and damp 
locality, will often induce it. Other depressing influences promote 
it, such as want of food, light, or warmth, sedentary habits, etc. But 
all of these often fail to generate any form of tubercular disease. 

4. Tuberculosis may be pathologically defined as a constitutional 
tendency to the formation of blood, the plasma of which is defective in 
organizable capacity; so that, in nutrition, instead of healthy tissue, 
it forms, in one, or very often in many, of the organs, aborted blas- 
tema, 2 which accumulates as a deposit. This deposit is called tubercle ; 
the process, tuberculization. 

5. But the tubercular diathesis (tuberculosis) may exist without 
tuberculization. Its influence is then shown, especially, in modifying 
inflammatory or other morbid processes ; giving them a loiuer, slower, 
and more persistent or intractable type. Thus, many cases of what 
is called tubercular meningitis in children occur, with fatal result, in 
which (Bouchut, Hughes Wilshire, etc.) no tubercular deposit is 
found; yet the disease is modified by the diathesis. 

6. Tubercle is distributed either in regularly-formed masses (miliary 
tubercles, etc.), or irregularly, through the tissue of organs. The 
most amorphous (shapeless) and homogeneous examples of it are 
called infiltrated tubercle. The size of the masses of tubercle varies 
from that of a pin's head to that of a hen's egg. 

7. The two essential varieties of tubercle are the semitransparent, 
gray, granular, and the yellow, opaque, caseous tubercle. 

8. Neither of these forms ever undergoes organization. They are 
never vascular. They are deposited outside of the bloodvessels only, 
and not in non-vascular tissues, such as cartilage, etc. 

9. The gray tubercle, when alone, is subject (Eokitansky) to one 
change only, comification ; i. e. drying into a horny substance as 

1 Dr. C. West is among those who deny this. Diseases of Children, Phil, ed., 
p. 583. 

2 From 9>Kdur<TAii», I bud ; used to mean tissue-forming material. This view 
of tubercle has been denied of late, it appears to me upon insufficient grounds, 
by Dr. T. K. Chambers and others. Some even assert a specific character in 
tubercle. Lebert, of Breslau, declares that he has propagated it in animals 
by inoculation. 



32 GENERAL PATHOLOGY. 

hard as a shot. When with the yellow tubercle, the gray may undergo 
softening. 

10. Yellow tubercle usually softens ; sometimes it cretifies ; % e. 
becomes chalk-like, by degeneration. 

11. The softening of tubercle is spontaneous; not depending upon 
any agency of surrounding parts. In regularly formed tubercles it 
commences at the centre; in the irregular, at any part. Tuberculous 
softening must not be confounded with suppuration of inflamed 
tissue ; although they are often mingled. 

12. Examined with the microscope, tubercle is found to consist 
essentially of: 1. An amorphous, granular material, containing irre- 
gular solid corpuscles (tubercle-corpuscles), considered (Yirchow) to 
be shrivelled nuclei. 2. Elements of disintegrated tissue of the 
part involved; as epithelial cells, fibres, etc. 3. Kesults of degenera- 
tion ; e. g. oil-globules, pigment, calcareous particles, etc. 4. Kesults 
of inflammation of surrounding parts ; lymph, pus, exudation-cor- 
puscles. 5. Extravasated blood-corpuscles, from hemorrhage, the 
effect of obstruction or ulceration of vascular trunks. 

13. Tubercle contains, then, no specific, heterologous form. All 
that it holds is the consequence of abortion and degeneration. 

14. The process of tuberculization or deposit of tubercle in the 
organ may occur (Rokitansky) — 

a. Insensibly, in the course of ordinary nutrition. 

b. With hyperaemia, or local determination of blood. 

c. With inflammation ; i. e. as a product or concomitant of the 
inflammatory process. 

15. The effects of the tubercular deposit upon the part are: 1. Ob- 
struction, and arrest or impairment of function. 2. Inflammation; 
e.g. in phthisis pulmonalis (consumption), which has, in its usual form, 
been designated (Condie) tubercular pneumonia, from the common 
occurrence of inflammation of the lungs with the deposit of tubercle. 
3. Ulcerative destruction of the tissue by the repeated new forma- 
tion and softening of tuberculous matter, producing cavities. 

16. Tubercle, once thrown out, is never (as a whole) absorbed. It 
can only be eliminated, cretified, or cornified. Elimination is the 
most common. After this has happened, sometimes callous cavities 
are formed by a process of cicatrization. 

17. The order of frequency with which different organs are affected 
with tubercle is (Rokitansky) as follows : — 

Lungs ; ' Spleen ; 

Intestines ; Kidneys ; 

Lymph glands; Liver; 

Larynx ; Bones ; 

Serous membranes ; Uterus ; 

Brain ; Testicles. 

Except in the case of children, in whom the lymph-glands and the 
spleen stand first on the list. 

18. But the organs most frequently first invaded by tubercle are, 
at all times of life, the lungs and lymph-glands. 

19. The parts especially preferred by tubercle for its deposit are, 
in the lungs, the apex ; in the pia mater, about the base of the brain ; 
in the brain, the gray substance ; in bones, the cancellated structure ; 



HYPERTROPHY. 33 

in the bowels, the lowest part of the ileum ; in the testicle, the 
epididymis ; in the female generative apparatus, the Fallopian tubes 
and fundus of the uterus. 

20. The immense experience of Rokitansky gives origin to the 
statement that tubercle has certain general incompatibilities ; the 
most important of which are, with cancer, with typhus, with ague, 
and with goitre (bronchocele, enlargement of the thyroid gland). 
These incompatibilities are. however, general, not universal ; as. for 
instance, a considerable number of cases have been observed, in which 
cancer and tubercle were undeniably present in the same patient. 

21. The only possible cure of tubercular disease (e. g. of the lungs 
in phthisis) after the deposit has occurred, consists in the total 
elimination (or absolute quiescence by cornification or cretification) 
of the tuberculous matter, and improvement in the general haematosis 
(i. e. blood-formation), so that no new tubercle is formed. The two 
great indications, therefore, in the treatment of pulmonary consump- 
tion (Radclyffe Hall) are, to gain time and tone: time, by allaying or 
preventing pulmonary or bronchial inflammation and irritation ; and 
tone, by strengthening the patient's system by all possible hygienic 
and therapeutic measures. 



GENERAL PATHOLOGY OF AFFECTIONS OF ORGANS. 

HYPERTROPHY. 

Hypertrophy is, strictly, overgrowth ; an increase of the size and 
weight of a part without change of tissue. It is only in recent times 
that this has been clearly distinguished from enlargement ivith altera- 
tion of tissue ; which is really, in many cases, a degenerative change, 
and therefore akin rather to atrophy than to hypertrophy. 

Hypertrophy is often, per se. physiological or natural ; although 
depending on a morbid or pathological cause. When the bladder, 
for instance, becomes hypertrophied in consequence of obstruction 
by an enlarged prostate, although the latter is morbid, the increase in 
the strength and thickness of the muscular coat of the bladder is as 
normal as is that of the uterus during gestation ; in due proportion to 
the necessities of its use. 

A constant law of the animal economy is, that, within certain limits, 
the growth of an organ is in proportion to its exercise ; provided 
that this exercise is not too violent, and is alternated with sufficient 
periods of repose. 

The three causes of hypertrophy, then, are (see Paget' 's Surgical 
Pathology) : — 

1. Increased exercise of a part in its healthy functions. 

2. Increased accumulation in the blood of the particular materials 
which a part appropriates in its nutrition or secretion. 

3. Increased afflux of healthy blood to the part. 

We may illustrate the first of these modes of causation by the 
blacksmith's arm, the legs of the danseuse, the cuticle of the laborer's 
hands, the heart in cases of valvular obstruction, etc. 



34 GENERAL PATHOLOGY. 

An example illustrative of the second is found in the enlargement 
of a healthy kidney, when the opposite one fails, from disease, to 
remove from the blood its due share of urea, etc. 

The third is exemplified in the large growth of hairs around an 
inflamed ulcer or osseous fracture ; by the growth of the bones of the 
limbs when their nutrition is increased by exercise ; by hypertrophy 
of a bone, a portion of which has been subject to disease with vascular 
excitement ; and by Hunter's interesting experiment of the trans- 
plantation of the spur of a cock to its comb. 

Adaptive hypertrophy is remarkably seen in the changes undergone 
by the skull in proportion to its contents. The cranium is subject 
to — 1, eccentric, and 2, concentric hypertrophy. The first occurs in 
cases of hydrocephalus, the second in cerebral atrophy ; the bony 
case in the one instance expanding with its contents, in the other 
thickening so as to fill up the abnormal void. 

Corns illustrate hypertrophy extremely well. 

Intermittent pressure, or attrition, causes hypertrophy ; constant 
pressure, atrophy or absorption. 

The formation of corns upon the foot illustrates the former of these 
laws ; the wasting away of vertebras under the incessant pressure of 
an aortic aneurism affords an example of the latter. The Chinese 
woman 's foot, with corns, exemplifying both. 

ATROPHY. 

Atrophy requires but a few words in this place. Simple atrophy is 
exactly the reverse of simple hypertrophy ; viz., wasting and diminu- 
tion of a part, without change of structure. But most pathologists 
include also under the same term such defects of nutrition as result 
in degenerative changes; constituting the two classes of — 1, quan- 
titative, and 2, qualitative atrophy. The latter (e. g. fatty degenera- 
tion) is frequently attended by increase instead of diminution of bulk 
in the parts affected. 

The causes of atrophy are : — ■ 

1. Deficient exercise of a part ; 

2. Deficiency in the supply of blood ; 

3. Defective supply of nervous influence ; 

4. Disease (inflammation, etc.) in the part. 

Of the first of these, the atrophy of the mamma of the old maid 
may afford an example. 

Of the second, softening of a portion of the brain from the ob- 
struction of one of its arteries by a coagulum. 

Of the third and first together, the muscles of a paralyzed limb. 

Of the last, there are many instances familiar to the pathologist, 
although obscurity often attends their individual history; as, the 
gouty kidney, etc. 

Quantitative or qualitative atrophy may affect the heart, arteries, 
brain, muscles, bones, liver, kidneys, pancreas, testicles, etc., and mor- 
bid products, e. g. inflammatory exudations, cancer, etc. 

Qualitative atrophy, or degeneration, will again be alluded to pre- 
sently. 



IRRITATION — INFLAMMATION. 35 



IRRITATION. 

Irritation and inflammation are at once the most familiar in their 
phenomena, and the most obscure in their nature, of all pathological 
processes or occurrences. I shall confine myself to a broad state- 
ment of what I believe to be the most important truths concerning 
them ; although a somewhat argumentative tone may be unavoidable, 
upon topics which are subject to so much controversy. 

Stimulation and irritation are often inconveniently confounded. 
It would be desirable to confine the former term to excitation within 
physiological (i. e. healthy or normal) limits ; applying the latter, irri- 
tation, only to such an excessive action upon a part as produces mor- 
bid effects. 

With this, which seems to me a necessary postulate — I would define 
irritation as an arrest of vital movement in a part. This could only 
be elucidated, by an extended allusion, inappropriate here, to the cor- 
relation of physical and vital forces ; life being considered as a 
moleadar motion. 

In regard to the circulation, to the old and accepted maxim — 
Ubi stimidns, ibi affluxus — 
may be added a second — 

Ubi irritatio, ibi stasis. 
And, anticipating the account about to be given of inflammation, a 
third— 

Ubi phlogosis, ibi effusio. 

The stasis of irritation maybe either partial or complete; limited 
to a very small surface, or widely extended; and transient, or continued 
for a considerable time. 

If complete, extended, and continued in a tissue at all vascular, in- 
flammation follows. 

If the influence of the irritant be very limited and transient, a 
temporary stasis and functional and sensational disturbance only fol- 
lows. 

If it be extended and continued, or repeated, and yet of power 
enough to produce a partial stasis only, a condition may result to 
which the name of chronic inflammation has (improperly) been 
commonly given ; of which more will be said hereafter. 

The effects, or symptoms, of irritation differ according to the tissue 
or organ affected. When a nervous expansion or centre is involved, 
pain is the most familiar result. Functional disorder of the part 
innervated also occurs. Irritation of muscular tissue causes tonic 
spasm. 

INFLAMMATION. 

Inflammation must be considered, briefly, as to its symptoms, mi- 
nute phenomena, products, terminations or effects, and post-mortem 
appearances. 

Its recognized symptoms or signs, in a part open to inspection, are 
redness, heat, swelling, and pain. 

In internal organs inflammation is detected chiefly by pain, 
increased by pressure or motion ; obstruction or alteration of the 



36 GENERAL PATHOLOGY. 

functional action of the organ; and general (sympathetic) vascular 
excitement. Certain physical signs also aid in the diagnosis of inflam- 
mation of particular organs (see Semeiology). 

The minute phenomena of inflammation, as seen under the micro- 
scope, have been variously construed by different observers. The use 
of the term itself has been, of late, distorted (Yirchow) from its old 
meaning ; and attempts have been made by some (Andral, Eisenmann, 
Bennett) to do away with it entirely; attempts which fail, because, in 
proposing other terms, a part only is substituted for the whole. It is 
curious, that, of the three terms proposed by three leading pathologi- 
cal writers, hyperemia, stasis, and exudation, to take the place of 
the old word inflammation, each expresses a single part or element of 
the process, which can only he defined hy including them all ; while 
cell-multiplication, made by Yirchow almost the whole of the process, 
is only an incidental attendant upon it. 

The essential minute phenomena of inflammation are, as regards 
the circulation, — 

Central stasis ; 

Concentric hyperemia; 

Exudation. 

Other changes, affecting the red and white corpuscles, etc., occur, 
but are of secondary consequence. 

The nature and cause of these phenomena require, for their com- 
prehension, a close consideration of the laws which govern nutrition, 
the capillary and arterial circulation, and innervation, in their mutual 
relations, under the influence of normal stimuli and of morbid irri- 
tants. 

What are the actual causes of inflammation ? 

Not section of the nerves; nor division of the arteries (perse); 
nor division of the veins ; nor ligation of arteries nor of veins ; nor 
(perse) of lymphatics. Only such causes as modify the molecular 
state of the tissue, and arrest, for the time, the usual interchange of 
material between the tissue and the blood, can induce a true inflam- 
mation. 

Let us, then, revert to our maxims. Ubi stimulus, ibi affluxus. 
Stimulation causes active hyperemia. The arteries thus exhibit re- 
flex action; a fact which, in spite of the teachings of Unzer, Hunter, 
and C. Bell, has been denied or misunderstood by nearly every other 
physiologist and pathologist down to the present day. 1 

1 Much of the accepted pathology of to-day, and some current notions in 
therapeutics, are founded upon an erroneous view of the physiology of the cir- 
culation, especially in regard to the mode of action of the arteries. The error 
is, the statement (based upon experiments whose results were only morbid, not 
normal) that the normal active contraction of the arteries always diminishes the 
supply of blood through them; as Virchow expresses it "the more active the 
vessel, the less the supply of blood." Another generation will attain to the 
correction of this ; and, with it, a revolution in the pathology of inflamma- 
tion must occur. See the author's Prize Essay on the Arterial Circulation. 
Trans. Amer. Med. Association, 1856. More recently (1858) Lister has as- 
serted reflex action as occurring in the vessels in inflammation ; as well as the 
central arrest of nutrition. 



INFLAMMATION. 3T 

Next, ubi irritatio, ibi stasis. Stimulation, carried to morbid ex- 
cess, interrupts, by the molecular disturbance it induces, the normal 
life-movement of the part, and checks the interchange of particles 
going on between the capillaries and the tissue. Thus the circulation 
in the capillaries of the 'part is arrested ; stagnation ensues. 

Both of these results, active arterial hyperemia and capillary stasis, 
follow from the same or similar causes acting in different degree. 
They may and do exist together; the one (capillary stasis) at the very 
point of irritation, the other (active hypersemia) in the vessels sur- 
rounding it. 

What follows ? Hydraulics may answer this question. A quantity 
of fluid, in (minutely) porous vessels, being forced upon a centre 
whose condition allows little or none of it to be transmitted, an effu- 
sion must result, through the more or less distended coats of the ves- 
sels. 

This is expressed by our third maxim: Ubi phlogosis (inflamma- 
tion), ibi effusio. This phenomenon, the " exudation," has attracted 
almost all the attention of many recent pathologists, to the exclusion 
of other occurrences, which precede and accompany it; an exclusion 
which has had detrimental results (J. Hughes Bennett) as regards 
the practical and therapeutical deductions made therefrom. 

Yirchow, of Berlin, has still another theory of inflammation, form- 
ing a part of his "Cellular Pathology." He identities (confounds) 
stimulation, which is physiological or healthy, with irritation, always 
abnormal or pathological in kind or degree. All irritation, in vascu- 
lar or non-vascular parts, is, in effect, either function al, nutritive, or 
formative. Exudation, or transudation of fluid into the substance of 
an inflamed part, is admitted only of the more vascular, soft, and super- 
ficial tissues. In others (parenchymatous inflammation) the essential 
effect of irritation of a high degree is said to be, the taking, by their 
own action or attraction, of more fluid into the cells of the organ or 
tissue. Thus they swell, and become clouded in aspect under the 
microscope. Next the nucleus divides; and afterwards the cells them- 
selves multiply by division, or proliferate. The origination of pus or 
other cells from entirely liquid lymph, as asserted by Paget and others, 
Virchow denies, in accordance with his maxim, "omnis cellula e cellula." 
Either the epithelial cells or those of the connective tissue (common 
germ-stock of all tissues) must give rise, by change, to pus-cells. At 
a certain stage, cell-enlargement and proliferation become destructive 
of function ; the parts then degenerate. But Yirchow does not with 
any distinctness at all state the relation between this degeneration 
and that nutritive or formative action which he considers the one 
effect of "irritation ;" nor does he allow to the condition of the blood- 
vessels any importance in what, in any tissue, he calls inflammation. 

This eminent pathologist has added to previous knowledge, that of 
the changes going on in the cells of an organ, a part of which is 
inflamed. These are important. But, he omits, in his account of the 
process, much ; and makes, on the whole, the least satisfactory theory 
of it now held by any authority. 

To return to our account of it ; an example of the three stages or 
processes of stimulation, irritation, and inflammation, may be well 
studied in the action of a common mustard plaster applied to the skin. 
4 



38 GENERAL PATHOLOGY. 

Its first effect (the only one if the mustard be diluted) is stimulant 
merely; the sldn grows warmer, and redder, and its sensibility is 
moderately heightened. Next (if it be strong and allowed to remain), 
irritation is produced ; shown by pain, tenderness on pressure, and 
a deeper or more purple redness. If the irritating matter be now 
withdrawn, all of these may subside without going further. But if the 
irritation be continued up to a certain point of duration and intensity, 
inflammation occurs. Then we have redness, heat, pain, and swelling, 
with effusion of lymph, which, after a sinapism or cantharidal plaster, 
raises the cuticle in a blister. 

I express then what I hold to be a correct theory of the nature of 
the inflammatory process, in this definition : Inflammation is a local 
lesion of nutrition, with concentric vascular excitement; resulting 
either in exudation or cell-distension and proliferation ; this last 
being destructive at the centre of the inflamed part, but often forma- 
tive around and at some distance from it. 

The products of inflammation (by exudation) are (see Pagefs Sur- 
gical Pathology) : 1. Serum. 2. Blood. 3. Mucus. 4. Lymph. 

The inflammatory effusion of non-fibrinous serum is rare. The 
term is often applied, however, clinically, to a serosity which contains 
a small proportion of fibrin ; as the effusion which follows pleurisy, etc. 

Blood is exuded occasionally only ; e. g. in dysentery, in nephritis, 
and (dissolved) in pneumonia. 

Mucus, a certain portion of which constantly moistens the surface 
of mucous membranes in health, is altered both in character and in 
amount by inflammation. The general statement is, that when a mu- 
cous membrane is inflamed (e. g. in bronchitis), its secretion of mucus 
is at first arrested, then increased, and lastly perverted in character. 

Coagulable lymph is, however, the characteristic ingredient of 
inflammatory exudations. 

Inflammatory lymph is divided by Paget into — 1, fibrinous, and 
2, corpuscular lymph ; with the assertion that, as a general fact, the 
more fibrin a specimen of lymph contains (provided it be healthy 
fibrin), the greater the probability of its being organized into tissue ; 
while the larger its proportion of corpuscles, the greater is the likeli- 
hood of suppuration or some other degenerative process, and the more 
tardy its development into any kind of tissue. (Note an apparent 
exception to this in the case of diphtheritic exudation ; explained by 
the fibrin of the latter not being healthy. See Rokitansky's Patho- 
logical Anatomy.) 

Fibrinous (coagulable or plastic) lymph is very well seen in the 
autopsy of any case of acute pleurisy, peritonitis, meningitis, &c. 

It is a whitish or yellowish-gray substance, opaque or semitranslu- 
cent after coagulation, arranged in fibrous bands, meshes, or layers, 
and causing adhesions between contiguous portions of the tissues 
affected. 

Corpuscular lymph may be studied in the fluid of the vesicles of 
herpes, or of an ordinary blister; especially if the surface of the latter 
have been exposed to the air for a short time. 

The lymph- or exudation-corpuscles which it is found (under the 
microscope) to contain, are about -^-550 of an inch in diameter, "round 
or oval, pellucid, but appearing, as if through irregularities of surface, 



INFLAMMATION. ' 39 

dimly nebulous or wrinkled.'' Examined after a few hours, under the 
action of water, a round and pellucid nucleus is observed within and 
attached to the cell-wall. It is, however, impossible, in a given 
instance, to make a positive microscopical diagnosis between these 
corpuscles of inflammatory lymph, and the normal lymph or chyle 
corpuscles, colorless corpuscles of the blood, and pus corpuscles. 

The ''biography" of the lymph of exudation consists in its resorp- 
tion, or its development into connective, fibrous, elastic, osseous, 
cartilaginous, or vascular tissue, or into epithelium, etc. (rarely into 
muscular or nervous tissue) ; or its degeneration into pus, or granule- 
cells, exudation granules, etc. 

The rapid resorption of a moderate amount of exuded lymph con- 
stitutes the resolution of an inflammation. 

Its development is also a form of resolution, but with modification 
of the condition, dimensions, etc. of the part. This is, in some in- 
stances, merely restorative. 

The degeneration of the exudation results in its being thrown off, 
as pus, or finally absorbed, in the form of molecular exudation-gran- 
ules. 

Whether immediate absorption, development, or suppurative or 
granular degeneration shall occur in any particular case of inflam- 
mation, will depend — 

1. On the state of the blood; 

2. On the seat of the inflammation ; 

3. On the degree of inflammation. 

(See Paget's 1 experiments as to the influence of the state of the 
Mood on the lymph of vesication.) 

As to the seat of the attack, generally, serous and synovial tissues 
(pleural, peritoneal, arachnoid, articular) are most subject to adhesive 
inflammation, i.e. with the exudation of fibrinous lymph. Mucous 
tissues seldom exhibit this, being more prone to suppurative inflam- 
mation. (Exceptions in croup, diphtheria, etc.) Parenchymatous 
tissues, as those of the lungs, liver, etc., when inflamed, may suppu- 
rate, or the lymph exuded may degenerate into exudation granules, 
and be finally absorbed. 

The degree of the inflammation exercises an important influence. 
The greater its intensity or severity [i. e. the more decided and ex- 
tended the local lesion of nutrition and concentric hyperemia), the 
farther will the lymph exuded be removed, in its primary character, 
from that transuded in the natural state of the part, and the more 
will its subsequent changes differ from those of normal nutrition and 
development. 

Degeneration may affect both the fibrinous and the corpuscular 
portion of inflammatory lymph. 

The fibrinous part is subject to — 

1. Drying into homy concretions (as on the valves of the heart, 
from endocarditis). 

2. Fatty softening. 

3. Liqupfactiue degeneration. 

Both of these last contribute, no doubt, to the process of suppura- 

1 Surgical Pathology, Phil, ed., p. 220. 



40 GENERAL PATHOLOGY. 

tion. Calcareous and pigmental degeneration are also described as 
occurring occasionally, but they are less important. 

The corpuscular portion of lymph may also undergo — 

1. Withering and drying (as in scrofulous inflammation of glands). 

2. Conversion into granule-cells (inflammatory globules of Gluge), 
by fatty degeneration. » 

3. Calcareous, 

4. Pigmental degeneration. 

5. Most commonly, degeneration of the lymph-cells into pus-cells ; 
the whole of the lymph being transformed into pus. 

Pus is a greenish-yellow, creamy fluid, consisting, under the micro- 
scope, of the liquor puris and pus-cells or corpuscles. The latter are 
definite cell forms, larger than blood or lymph corpuscles, somewhat 
more irregular, and often containing several nuclei. Their characters, 
however, are not invariably distinctive ; as might be anticipated, 
from their being merely transformed or degenerated lymph or epi- 
thelial corpuscles; or, in a wound or ulcer, cells of granulation. 
Chemically, pus may be approximatively tested by its solubility in 
liquor potassce. 

Suppuration is either circumscribed (as in abscess), diffusive 
(in erysipelas), or superficial (in leucorrhcea, etc.) 

The effects of inflammation upon the part or organ involved are — 
Enlargement; Degeneration; 

Induration ; Ulceration ; 

Softening ; Mortification. 

We thus see that very different or even opposite results may follow 
from different degrees or kinds of inflammatory action. 

Specific inflammations require merely to be mentioned here. They 
are, chiefly, scrofulous, erysipelatous, rheumatic, gouty, exanthe- 
matous, syphilitic, gonorrhceal. These are distinguished from ordi- 
nary inflammation and from each other in that — 1, each exhibits a 
peculiar plan of morbid process ; 2, each depends upon a peculiar 
cause; 3, the effects of the said cause are irrespective of its quantity 
or extent of application ; 4, they are especially diffusible from one 
part of the body to another ; 5, they sometimes exhibit definite stages 
of the morbid process (e. g. primary and secondary syphilis) ; 6, they 
are nearly all, in a more strict sense than other inflammations, self- 
; limited ; the morbid process dying out after a certain time. (This 
last statement applies especially, if not only, to exanthematous, rheu- 
matic, gouty, and gonorrhoeal inflammations ; hardly to the scrofulous, 
erysipelatous, and syphilitic.) 

The post-mortem appearances of inflammation are important. 
They can be generalized, so as to avoid, to a great extent, the neces- 
sity of their reiteration in connection with the description of particu- 
lar diseases. It is, at the same time, necessary for the student to 
familiarize himself with them, in their local manifestations, by avail- 
ing himself of every opportunity for autopsic study. 

A part which has been inflamed will exhibit after death some, or 
perhaps all, of the following signs : — 



CHRONIC INFLAMMATION. 41 

Redness ; Coagulable lymph ; 

Enlargement of Pus ; 

bloodvessels; Softening; 

Tumefaction*; Induration. 

The redness of inflammation must be distiuguished with care from 
— 1, hypostatic injection, or cadaveric settling of blood in the lowest 
parts, by gravitation ; and 2, physiological redness, as of the stomach 
during digestion, the ovaries during menstruation, etc. Inflammatory 
redness is usually more unequal than either of the above, and is 
stellated, or in streaks and patches. 

Enlargement of the bloodvessels of a part may occur as the result 
of a chronic affection, different from acute inflammation. This sign, 
therefore, is to be interpreted with great caution. The same is true 
of tumefaction. 

Softening, if not cadaveric (as when the body has been long de- 
funct), may have been produced by chemical action, as in poisoning 
by corrosive sublimate, etc., by acute and rapid inflammation, or by 
sloiv, non-inflammatory degeneration. 

Induration may also follow either acute inflammation or slow, 
atrophic degeneration. 

The presence of bands or membranes of coagulable lymph is 
indisputable evidence of inflammation having occurred in the part. 
But it is not easy, in all cases, to determine with certainty whether 
such formations are old or new. 

The existence of pus is a still stronger sign of the recent existence 
of inflammation; but, occasionally, instances occur in which pus, 
produced by inflammation in one part, is conveyed (as in phlebitis) 
by the veins, etc., and deposited in another. This, although a rare 
event, is possible at least. 

Clearly, therefore, no one of the above post-mortem signs of inflam- 
mation is sufficient alone. Several of them together will make the 
diagnosis certain. Bedness and enlargement of bloodvessels, with 
lymph ov pus, and softening or slight induration of tissue, will leave 
little or no doubt in any case. 

The variations in the appearance of different organs and portions 
of the body, in fatal cases of inflammatory disease, are not such as 
to interfere with the correctness and availability of this general de- 
scription. 

CHRONIC INFLAMMATION. 

The term " chronic inflammation," as commonly applied, is a 
misnomer. Although the cases so designated exhibit more or less 
redness, heat, swelling, and pain, yet they are wanting in exudation ; 
without which, pathologically, there is no inflammation. There is 
also, in the same cases, only a partial stasis or none ; and the hy- 
peremia is less intense and less strictly concentric than in acute 
inflammation. 

The characteristics of this state, for which a new term is wanted, 
are — 

1. Enlargement of the bloodvessels of a part (chronic hyperae- 
mia), with the flow of a large amount of blood through, it. 

4* 



42 GENERAL PATHOLOGY. 

2. Exaggeration of the sensibility of the part (hyperesthesia) and 
morbid irritability. 

3. Deficient or irregular functional power. 

4. Unusual proneness to acute or subacute attacks of actual in- 
flammation. 

For this familiar combination of pathological elements I propose 
the name hyper aemaesthesia. 

It has, lately, been usual to designate it by the term "irritable," 
in connection with the name of the particular part affected, thus — 

Irritable uterus ; 

Spinal irritation ; 
to which I would add — 

Irritable eye (chronic ophthalmia) ; 

Irritable stomach (chronic gastritis) ; 

Irritable brain, etc. 

DEGENERATION. 

Degeneration has been already defined as qualitative atrophy; i. e. 
a substitution, under decline of the organic force incessantly active in 
nutrition and repair, of abnormal for normal structure and material. 
The forms under which this occurs are — 
Fatty degeneration ; 
Calcification ; 
Pigmental degeneration ; 
Fibroid, colloid, or amyloid degeneration ; J 
Liquefactive and corpuscular degeneration. 
In regard to all of these except the last, it may be stated (see Pa- 
get's Surgical Pathology) that 

1. They are changes such as may be observed naturally occurring, 
in one or more parts of the body, at the approach of the natural 
termination of life. 

2. The new material is of lower chemical composition than that 
normal to the part ; i. e. it is less removed from the inorganic state : 
as fat, gelatin, calcareous matter, etc. 

3. In structure, it is less developed ; being crystalline, granular, 
simply globular, etc. 

4. In function, it is less powerful. 

5. In nutrition, it is less active and capacious. 

6. Generally, although not always, constitutional debilitation pre- 
cedes, and (we may infer) institutes the local alteration of structure. 

7. Inflammation or other local disease may, by impairing the 
nutrition of a part, cause it to degenerate. 

The form of degenerative disease which has received the most 
attention from pathologists is fatty degeneration. This has been 
carefully studied, as it occurs in the heart, arteries, brain, muscles, 

1 Amyloid degeneration has been described by Vircbow and others, as oc- 
curring in the brain, spleen, liver, etc. It consists in the conversion of tissue 
into a substance having physical and chemical properties resembling those of 
starch or cellulose. 



DEGENERATION — CANCER. 43 

liver, kidneys, and mc lactg. It must be distingui 

rally from mere fatl ry. 

Our knowledge of the nceming degenerative disease, an 

the share which it claims in the domau lctaral pal once 

almost entirely usurped by inflammation, is among the most important 
of the acquisitions of the medical science of the last quarter 
century. 

Tumors, and morbid growths, benign and malignant, which may 
be best classified as forms of structural degeneration, or vitiated 
nutrition. I leave, at present. — except some brief consideration of the 
pathology of cancer. 

Cancer falls under the notice and care of the medical practiti: 
when it attacks parts or organs within any of the great cavities of 
the body. 

There is no essential impropriety in classing, pathologically, 
malignant g-". aether as cancerous: : being 

clinical or surgical. (By malignant, we mean, prone to unlimited 
increase : lit ; and difficult or iniy 

arrest or cure.) 

ancers may. then, be divided simply into 

Scirrhus. or hard cancer (fibro-carcinoma) ; 
I .';"."..::. >i trelatinifonn alveolar) cancc 
Encephaloid. or brain-like (medullary) cancer. 2 
Each of these contains, as its anatomical elements, fibres, fluid, or 
semi-fluid jelly, and cells. 

Scirrhus is composed mainly of a fibrous or filamentov.- 
with little fluid, and comparatively few cells. It never become 
cephaloid. nor does encephaloid cancer - me scirrh 

Colloid cancer has a variable amount of fibrous tissue, arrayed as 
trix compared often to the structure of an orange lining 

icej sells may be also found in it. but in less pro- 
portion. 

Encephaloid cancer is (so to speak) the highest development of 
carcinomatous formation. It consists of a fibrous matri uning 

an abundance of abnormal, multiform cells, and a peculiar fluid. 

When a cancer, of either type originally, is based upon and includes 
bony structure, it constitutes oste j-sarcoma. If it develop itself upon 
the skin, or other epitl wherever occurring, display 

similar structure, it may be called t ± .:. If its loca 

involve especial va and hemorrhage, it assumes the form and 

nam- ji of cancer (which is not always 

jars to depend upon the extension of the disease to a 
U endowed with nerves. 
The cells, fibres and fluid 3 of cancer are all abnormal. 

1 Tubercle, it will be remembered, is not a growth, but an abortion of tissue, 
ner names are frequently used, as y it dial, melanoid, osteoid, hama- 

toid, and villous cancer. 

- The milky or creamy "cancer-juice. 1 '' which emulsifies with water, is con- 
sidered highly characteristic by many observers. Tiie mal-.^ gone- 
ness to increase, and e: of a tumor, is generally in proportion 
to its succulence or juiciness. 



GENERAL PATHOLOGY. 

Cancer-cells are of various shapes, resembling gland-cells, but 
larger, averaging about jqVo °f an mcn ^ n diameter. 

But, are these forms heterologous ; i. e. different from anything 
normal or natural to the body ? Are they, so to speak, implantations, 
or distortions ? I believe, fully, that the latter is the correct view. 
The " cancer-cells" are no longer held by micrologists to be pathog- 
nomonically distinctive ; they are homologous with other cells found 
in the body. Yet, they are such forms as do not normally belong to 
the part ; being produced by morbid alteration or perversion of its 
natural elements. 

The most rational theory of cancer, then, is dynamic. The disease 
consists in a morbid tendency ; a tendency to enormous and unhealthy 
growth of a formation which is, at the same time, vascular and sen- 
sitive, showing subserviency, although under perversion, to the physio- 
logical laws of the organization. 

The origin of cancer, in many cases, is constitutional; it is not 
unfrequently hereditary. 

Genuine cancer may always be expected to return after removal — 
although exceptions occur, and it has occasionally been known to 
undergo spontaneous degeneration. 

The order of choice which cancer exhibits, as to the parts it attacks, 
is (Rokitansky) as follows : — 

Uterus ; Liver ; Testicle ; 

Mamma; Bones; Ovary; 

Stomach ; Skin ; Tongue ; 

Rectum ; Brain ; (Esophagus. 

Lymph-glands ; Eye ; 

Colloid cancer, in particular, prefers the 

Stomach, rectum, peritoneum. 
Scirrhus, the 

Mamma, stomach, intestines. 
Encephaloid may occur in any organ ; it alone attacks the 
Liver, kidney, lung, testicle, eye, lymph-glands. 1 

NEUROPATHOLOGY. 

The pathology of the nervous system is, itself, an extensive field, 
of which the merest coup d'oeil is possible here. 

For the purposes of pathological study, we must remember that the 
anatomical elements of the nervous apparatus are — 1, gray, vesicu- 
lar ; and 2, white, tubular nervous substance ; the former being ar- 
ranged in ganglia, the latter in nerves and commissures. 

Physiologically, the functions of the ganglia (nevve-centres, and, 
probably, impressible peripheral ganglionic expansions also) are, to 
receive, reflect, accumulate (generate?), and distribute nerve-force. 
The sole function of nerves and commissures is, to transmit or con- 
duct it. 

As a whole, we may state the offices of the nervous apparatus to 
be as follows : — 

1 Dr. DaCosta has recently noticed an unusually low temperature of the 
body in cancerous patients. 



NEUROPATHOLOGY. 45 

Excito-motor ; Internuncial, i. e. 

Excito-secretory ; Sympathetic and 

Sensory; Synergic (co-ordinative) ; 

Voluntary motor ; Psychical, i. e. 

Intellectual ; 
Emotional. 
The primary disorders to which this apparatus is liable, are (see 
Simon's Lectures on Pathology) : — 

1. Anaesthesia; •". e. that condition in which the patient remains 
without cognizance of impressions made on a surface which is nor- 
mally sentient. This may result, a, from disease of the nervous ex- 
pansion at the surface ; b, from disease or injury of the conducting 
nerve, somewhere on its track ; c, from disease of the cerebral sub- 
centre of sensation (sensorium). The thalami (miscalled optic) are 
believed by physiologists generally to be the aggregative centres of 
sensation; and local lesion (apoplectic clots, tumors, softening, etc.) 
in or near them is frequently associated with hemiplegia, etc. The 
paralysis is commonly observed (from decussation of the nerve fibres 
in the medulla oblongata) on the side opposite to that on which the 
lesion has occurred. 

2. Subjective impressions and sensations ; i. e. those which affect 
the consciousness of the individual without the action of any external 
or peripheral cause. These subjective impressions may be divided 
into — a, those which are central in their origin, as when disease of 
the optic thalamus causes neuralgia of the fifth pair of nerves ; and 
b, those whose origin is intermediate ; as, when inflammation of the 
sheath of a nerve, or disease of the spinal axis, gives rise to pain 
referred by the patient to the termination of the nerve. 

Subjective hyperesthesia, or perversion of sensibility or psychical 
impressibility, may be, in its causation (as regards the nervous appa- 
ratus), either functional 1 or organic; and the difference between 
these is often practically important. 

3. Muscular paralysis ; or that condition in which a central voli- 
tion (or the excitation equivalent to it) fails to produce its normal 
effect of muscular contraction. Of this defect, also, the pathological 
origin may be, as to its seat, either peripheral, intermediate, sub- 
central (in the corpora striata or cerebellum), or central (in the con- 
volutions of the cerebrum). Muscular as well as sensational paralysis, 
dependent on an affection of the brain, occurs on the opposite side to 
that of the encephalic lesion. Hemiplegia and paraplegia have 
already been defined (see Semeiology). Scarcely ever are either of 
these varieties of palsy confined exclusively to sensation or to volun- 
tary motion — although the proportion of impairment of the two func- 
tions may vary considerably in particular cases. Both, kinds are 
occasionally reflex (Brown-Sequard). 

4. Involuntary contraction of voluntary muscles, or convulsion. 
Only very local, and usually transitory spasmodic affections are peri- 
pheral in their origin. Usually, convulsive affections are accounted 
for by excessive functional excitement of the (spinal) motor centres; 

1 Functional nervous disorder results generally (Todd) from an abnormal 
state of the blood. 



46 GENERAL PATHOLOGY. 

the causation of which is made up of three elements, in variable pro- 
portion, viz. : a, morbid irritability of the spinal excito-motor appa- 
ratus itself; b, imperfect control over the subordinate nervous centres 
by the brain, from an abnormal condition of the latter ; c, the dis- 
turbing influence of a peripheral irritant — as, the tension of the 
gums in teething, worms in the bowels, undigested food in the stomach, 
etc. 

The three forms of spasmodic disturbance to which the muscles are 
liable under a morbid alteration of innervation, viz. : the tonic, 
choreic, and clonic, are illustrated respectively in tetanus, chorea, 
and epilepsy. 

5. Excito-secretory action (Longet, Campbell) becomes morbid 
under conditions often like those which produce convulsion ; for ex- 
ample, the diarrhoea of infants, so common at the time of dentition. 

A subject of great interest, almost neglected until within the last 
ten years, is that of the effects of various agencies, through the 
nerve-centres, upon the bloodvessels. But while the vaso-motor 
nerves are now recognized, and their special relation to the ganglionic 
or sympathetic system is beginning to be appreciated, a remarkable 
confusion on this subject pervades the medical literature of the present 
time. 

The therapeutic system (neuro-pathy — ganglio-therapy) associated 
with the name of Dr. John Chapman, will receive attention under 
general therapeutics, 

A farther important pathological subdivision exists as to the method 
of origination of those functional disturbances of the nervous system 
to which we have been alluding. 

The source of any of the above forms of nervous disorder, hyper- 
esthesia, anaesthesia, muscular paralysis, or convulsion, may be (when 
not purely local) either 

1. Central organic disease ; 

2. Blood-perversion, or defective nutrition; 

3. Purely sympathetic disturbance. 

It is far from easy, in many cases, to mark the diagnosis between 
these different modes of causation of nervous symptoms ; but, when 
the decision has been made, in any instance, the prognosis is most 
favorable in the last case ; less so in the second ; and most unfavorable 
in the first, i. e. when the symptoms have their origin in an actual 
organic lesion of an important nerve-centre. 

' Other subjects (hemorrhage, dropsy, &c.) which might be considered 
as belonging to general pathology, will be taken up in Part II. of this 
book. 

MODES OF DEATH. 

Death may occur 

1st. By asthenia ; the dynamic force of the system being exhausted 
or destroyed, so that the heart ceases to beat ; as in lightning-stroke, 
poisoning by prussic acid, &c. Syncope (fainting) simulates or 
threatens this. 

2d. By anaemia ; the blood being rendered insufficient for life ; as 
from hemorrhage after labor, surgical injuries, bursting of aneurisms, 
&c. 



SYMPTOMATOLOGY. 47 

3d. By apnoea, or asphyxia; that is, arrest of respiration, either 
from disease of the lungs, obstruction of the air-passages, deficiency 
or impurity of the air. 

4th. By coma; the brain and medulla being made incapable of sus- 
taining innervation ; as in apoplexy, opium poisoning, &c 
Sudden death may occur from 

Apoplexy ; 

Valvular heart-disease (especially mitral) ; 

Rupture of heart (or syncope) in fatty degeneration ; 

Bursting of an aneurism, or abscess, within the thorax or abdomen ; 

Suffocation ; 

Violent mental shock or alarm. 



SECTIOX II. 

SEMEIOLOGY. 

I. RATIONAL SYMPTOMATOLOGY. 
II. PHYSICAL DIAGNOSIS. 

Rational symptoms and physical signs are distinguished (some- 
what arbitrarily) thus : a rational symptom is a sign of disease which 
is obvious to the patient himself or to the practitioner without close 
inspection. A physical sign is one determined by examination into 
the properties and material conditions of the organs of the body ; as 
by palpation, auscultation, percussion, etc. Symptoms guide us, gen- 
erally, by physiological inference; physical signs, by anatomical neces- 
sity. 

Symptoms and physical signs together contribute to diagnosis; 
i. e. the knowledge of the character of the morbid process or state 
in given cases ; the answer to the question, " what is the matter ?" 

Prognosis is the anticipation of the progress and results or termi- 
nations of disease. The essential elements of prognosis are, a know- 
ledge of the cause or causes of disease present ; of the condition of 
the organs ; and of the general vital state, or degree of vital force of 
the system. Prognosis depends therefore upon diagnosis ; but is 
governed, in a majority of cases, chiefly by those rational symptoms 
which indicate the organic energy of the patient, and the kind and 
rate of change that his system is undergoing. 

SYMPTOMATOLOGY. 

Symptoms, or rational signs, are- 
Local, or constitutional ; 
Idiopathic (primary), or secondary ; 
Premonitory (prodromata) ; 
Critical ; 
Pathognomonic (characteristic). 



48 SEMEIOLOGY. 

"We examine the symptoms of disease as connected with the diges- 
tive, circulatory, respiratory, tegumentary, secretory, motor, sensory, 
and psychical apparatus. 

SYMPTOMS CONNECTED WITH THE DIGESTIVE SYSTEM. 

The tongue may be natural, pale, cold, red, furred, brown, black, 
cracked, or fissured. 
It is pale, in anaemia. 
Cold, in collapse, as of cholera, etc. 
Bed, in scarlatina, stomatitis, sometimes in gastritis. 
Furred, in indigestion, gastro-hepatic catarrh, fever, etc. 
Brown or black, cracked or fissured, in low fevers : as typhus or 
typhoid. 

Protruded with difficulty, in low fevers, and in apoplexy ; to one 
side, in paralysis. 

The manner of cleaning of the tongue during convalescence should 
also be noticed, as affording prognostic indications. 
The teeth, are covered with sorcles in low febrile states. 
They are loosened by severe salivation. 

Their rapid decay shows impairment of constitution : but this is 
unfortunately very common. 

The gums are swollen, soft, and spongy, and prone to bleed, in 
scurvy. 
A blue line along the gums is observed in lead poisoning. 
A red line along their edge is sometimes noticed in phthisis. 
Swelling and soreness of the gums, with tenderness of the teeth, 
and a coppery taste, occur in salivation. 

Increased flow of saliva gives name to this effect of mercury on 
the mouth. 

Deficiency and thickness or viscidity of the saliva occurs generally 
during fever ; and often also in chronic diseases, especially of the 
throat and stomach. 
The taste is morbidly 

Bitter, in hepatic derangements, dyspepsia, etc.; 
Sour, in gastric indigestion ; 
Saltish, in phthisis pulmonalis, haemoptysis, etc.; 
Putrid, in gangrene of the lungs. 
Appetite is generally deficient (anorexia) in disease, especially of 
an acute character. 

Excessive appetite (bulimia) is not often important ; sometimes it 
occurs in nervous affections, in diabetes, and in persons having worms 
in the alimentary canal. 

Perverted, appetite is one of the symptoms of chlorosis, hysteria, etc. 
Thirst is excessive in two very opposite conditions : high fever and 
low collapse. 

Difficulty of Swallowing [dysphagia) may result from — 
Inflammation of the fauces, tonsils, or pharynx ; 
Spasmodic constriction of the throat ; 
Stricture of the pharynx or oesophagus ; 
Obstruction by a foreign body, tumor, etc. ; 
Betro-pharyngeal abscess ; 
General debility, as in the moribund state. 



SYMPTOMS — CIRCULATORY SYSTEM. 49 

Nausea and vomiting may occur from— 

Indigestion : egesta. 1 partly digested food, mucus, etc. ; 

Colic : eg., ditto, bile, etc. ; 

Pregnancy : eg., mucus, food, etc. ; 

Gastritis : eg., abundaut and altered mucus, etc. ; 

Hysteria : eg., gastric and biliary secretions, more or less al- 
tered ; 

Cholera morbus : eg., gastric and biliary secretions, diluted ; 

Clwlera maligna : eg., copious watery fluid (rice-water) ; 

Bilious fever : eg., altered mucus, bile, &c. ; 

Yellow fever: eg. (advanced stage) black vomit; 

Ulcer of stomach: eg., mucus, lymph, blood ; 

Cancer of stomach: eg., ditto, with caueer-cells, fibres, etc. ; 
N Disease of the brain : eg., not peculiar in character. 

Bright' } s disease of kidney : eg., not peculiar ; 

Strangulated hernia: eg., stercoraceous (faecal) ; 

Poisoning : as by tartar emetic, arsenic, &c. 

Sarcince, or microscopic, wool-sack like vegetable parasites, are 

occasionally found in matters vomited, in cases of disease of the 

stomach. Epithelial cells, starch granules, toruhe (also vegetable) 

and vibriones (animalcular) are often discovered by the microscope. 

SYMPTOMS CONNECTED WITH THE CIRCULATORY SYSTEM. 

Palpitation or disturbed action of the heart may depend upon— 

Pericarditis or endocarditis ; 

Hypertrophy of the heart ; 

Chronic valvular disease; 

Ancemia ; 

Nervous irritability (nervousness) ; 

Disorder of the brain; 

Dyspepsia. 
The pulse should be examined when the mind and body of the 
patient are as tranquil as possible. It is most rapid in the standing 
posture, less so when sitting, slowest in the recumbent position. Dr. 
Guy asserts it to be most rapid in the morning. It is increased in 
force and frequency by exercise, food, and emotional excitement. The 
pulse of the female is slightly more rapid, as a rule, than that of the 
male sex. It diminishes in rapidity from birth to old age; but in 
very aged people it again becomes somewhat accelerated. 

In obscure cases we should examine the pulsation of other arteries 
besides those at the wrist ; and should especially observe the charac- 
ter of the impulse of the heart. 

In adults, the average number of beats in health is, for the male, 
70 ; for the female, 75. 

At birth, 120 to 140. Middle life. 75 to 65. 

Infancy, 120 to 100. Old age, 70 to 60. 

Childhood, 100 to 90. Decrepit age. 75 to 80. 

Youth, 90 to 75. 
We judge by the pulse (inferentially) of the force of the heart's 

1 Egesta, matters thrown out. 



50 SEMEIOLOGY. 

action, of the force of the arterial impulse, of the excitability of 
the nervous system, of the fulness of the bloodvessels, and of the 
tone and physical condition of the arteries. 

The pulse in disease may be natural, or strong, weak, firm, yielding, 
full, small, bounding, compressible, rapid, slow, quick, jerking, hard, 
soft, tense, gaseous, corded, wiry, thready, imperceptible, regular, 
irregular, intermittent, dicrotous. 

N ot considering it necessary here to define each of these terms, it 
may be remarked that an important difference exists between a rapid 
pulse and a quick pulse, and between one that is merely full and large 
and one that is strong. 

The pulse of fever is characterized by moderate acceleration, with 
variable increase of force in the beat. 

The pulse of inflammation (with constitutional excitement) is not 
only accelerated, but hard or tense, and, commonly, full. Whatever 
may be said to the contrary, this character of the pulse is, in acute 
inflammations, of great consequence as an indication of treatment ; 
although, of course, it must not be depended on alone. 

The pulse of nervous irritation is usually quick, and variable in 
rapidity and force, under excitement or repose. 

A jerking, abrupt pulse is associated (Stokes) with deficiency of the 
aortic valve. 

The pulse of extreme debility is nearly always (as in the dying state) 
very rapid and very small, or " thready." 

Irregularity of the pulse is occasionally congenital ; sometimes it 
comes on with old age. It may be a transient symptom, accidental, 
as it were, during the progress of an acute malady; or at the com- 
mencement of convalescence, as from remittent fever. It is directly 
related to the nature of the disease, in certain cases of disease of the 
heart, and in meningitis (inflammation of the membranes of the brain) 
during the stage of effusion. 

The dicrotous or double pulse is observed especially during con- 
tinued fevers, either typhous or typhoid. It is explained by a loss of 
muscular tone in the arteries, so that the arterial impulse is separated 
from that of the ventricles by a perceptible (though slight) interval. 

The state of the capillary and venous circulation often affords 
signs of disease. Torpor of the circulation is marked by slowness in 
the return of the blood after it has been displaced by pressure ; for 
instance, upon the cheek or the back of the hand. The veins of the 
hand or arm may be similarly examined with advantage ; as in cholera, 
pernicious intermittent, low continued fever ; etc. The venous circu- 
lation is affected not unfrequently in heart-disease : e. g. pulsation of 
the jugular veins, from valvular disease involving the right side of the 
heart ; cyanosis, or blueness, from imperfect separation of the arterial 
from the venous blood, etc. 

Pulsation of the veins does not, however (notwithstanding the 
dictum of authorities), always depend upon disorder of the heart. 
The author has seen three cases in which jugular pulsation was evi- 
dently the result of local irritation, exaggerating the muscular activity 
resident in the organic muscle-fibres of the vein. 

The blood itself is perhaps the most important of all subjects of 



SYMPTOMS — CIRCULATORY SYSTEM. 51 

inquiry in connection with disease. Little, however, as yet, is known 
of its morbid changes. The principal facts are, that — 
In ancemia, there is a deficiency of the red corpuscles ; 
In plethora, an excess of the red corpuscles ; 
In leucocythemia, an excess of the colorless corpuscles ; 
In inflammation, and in chlorosis, excess of fibrin ; 
In gout, excess of uric acid ; 
In rheumatism (perhaps), excess of lactic acid ; 
In melanaemia, excess of free pigment ; 
In jaundice, excess of biliary matter; 
In BrighVs disease, excess of urea, etc. (uraemia) ; 
In diabetes, excess of sugar ; 

In malignant cholera, deficiency of water and salts. 
These peculiarities require minute inspection, with the aid of the 
microscope or of chemical reagents. To the eye. differences sometimes 
exist which may be instructive : e. g. as to the bright red or very dark 
color of the blood ; as to the magnitude, form, and firmness of the 
clot, and the rapidity of coagulation, etc. 

In cases of lingering prostration, clots may form in the heart or 
large arteries before death. After very rapid malignant diseases, the 
blood is sometimes found uncoagulable. 

Hemorrhage from different parts of the body is often important as 

a symptom, but requires to be interpreted with care. Its consequence 

varies much with its quantity, and the source of the blood thrown out. 

Thus, in epistaxis, or bleeding at the nose, the flow may result 

from — 

Meclianical injury ; 

Congestion of the Schneiderian membrane ; 
Congestion of the brain; 
Typhoid fever ; 
Hemorrhagic diathesis ; 
Suppressed menstruation. 
This variety of hemorrhage is, however, most frequent during 
childhood and early adolescence. 

In haemoptysis, or spitting of blood, the source of the hemorrhage 
may be the — 
Gums ; 

Posterior nares ; 
Throat (e. g. ulcerations, etc.) ; 
Bronchial mucous membrane ; 
Lungs ; 
Stomach. 
In the last case, being vomited into the mouth, it is properly called 
haematemesis. Sometimes it requires care to determine what is the 
source of blood coming from the mouth. We must notice what are 
the symptoms preceding the hemorrhage ; and the manner of its ejec- 
tion, whether by coughing or vomiting, etc., as well as the appearance 
of the blood, whether mixed with food, gastric fluid, etc. 
True pulmonary haemoptysis may arise from — 
Active congestion of the lungs ; 
Passive congestion, from heart disease ; 
Tubercular phthisis ; 



52 SEMEIOLOGY 

Hemorrlx agic diathesis ; 

Vicarious monthly flow, in the female ; 

Mechanical injury, as fractured rib, etc. ; 

Rupture of aortic aneurism. 
Haematemesis, or vomiting of blood, may be — 

Hysterical ; 

Ulcerative ; 

Cancerous ; 

Vicarious ; etc. 
Uterine hemorrhage, other than the normal menses, may be — 
. Congestive ; 

Ulcerative ; 

Cancerous ; as well as, in the pregnant female, placental, tech- 
nically called '" unavoidable hemorrhage;" that of abortion ; 
or, after parturition. 
Hemorrhage from the bowels may be connected with—- 

Hemorrhoids, or piles ; 

Dysentery ; 

Ulceration of the bowel; 

Intussusception ; 

Cancer of rectum, etc. ; 

Rupture of aneurism ; 

Hemorrhagic diathesis ; 

Typhoid, or yellow fever ; 

Vicarious menstruation. 
Haematuria, or bloody urine, may result from — 

Mechanical injury of the bladder, prostate gland, or urethra ; 

Renal inflammation ; 

Calculus ; 

Hemorrhagic diathesis ; 

Passive senile congestion of the "kidneys ; 

Scarlatina. 

SYMPTOMS CONNECTED WITH THE RESPIRATORY ORGANS. 

The normal, average rate of breathing in the adult, while at rest, is 
sixteen or eighteen respirations in the minute. In fever it is much 
accelerated. In extreme narcotism it becomes slower than natural. 
In some cases of fatty degeneration of the heart it is sighing and 
interrupted. 

Dyspnoea, or difficulty of breathing, when great, is called or- 
thopnoea, from the erect posture required by the patient. Cervical 
respiration occurs in cases of great exhaustion, or of obstruction of 
the respiratory function by disease. 
Dyspnoea may be caused by — 

Chlorine or other irrespirable gases in the air ; 

Morbid change of the blood, as in cholera ; 

Laryngeal or tracheal obstruction, as in croup, etc. ; 

Bronchial spasmodic constriction, as in asthma ; 

Bronchitis ; pneumonia; pleurisy ; phthisis; 

Heart disease; aneurism of thoracic aorta; 

Cancer within the chest ; hydrothorax; ascites. 



SYMPTOMS — TEGUMENTARY APPARATUS. 53 

Coughing may depend upon a variety of causes, the nature of 
which may often be concluded upon from its character. Thus, usually, 
Cough is dry and hollow, or hacking, when nervous or sympa- 
thetic ; 
Dry and tight, in early bronchitis ; 
Soft, deep, and loose, in advanced bronchitis ; 
Hacking, in incipient phthisis pulmonalis ; 
Deep and distressing, in confirmed consumption; 
Short and sharp, in pneumonia; 
Barking and hoarse, in early or spasmodic croup ; 
Whistling, in advanced membranous croup ; 
Paroxysmal, and whooping, in pertussis. 
Expectoration is— 

Mucous, in catarrh, and early bronchitis ; 
Purulent, in severe and protracted bronchitis ; 
Rusty, in the early and middle stages of pueumonia; 
Bloody and muco-purulent, in phthisis ; 
Nummular and heavy, etc., in advanced phthisis; 1 
Putrid, in gangrene of the lung. 
The temperature of the breath is increased during the febrile state. 
It is lowered, sensibly, only in aggravated prostration ; as in the col- 
lapse of cholera. Coldness of the breath is an almost certain prog- 
nostic of dissolution. 

The odor of the breath is rarely perfectly agreeable except in the 
healthy infant or child. It is very heavy at the commencement of 
fever ; sour during indigestion ; offensive, often, from decayed teeth ; 
rotten, in gangrene of the lung. 

Hiccough (singultus) is produced by a spasm of the diaphragm. 
It may depend upon indigestion, nervous disorder, or exhaustion. It 
is serious in prognosis only when the latter is present or is anticipated. 
Stertorous respiration, from relaxation of the velum pcdati, results 
from cerebral oppression ; the cause of which may be apoplexy, frac- 
ture of the skull, dead drunkenness, or narcotism by opium, etc. 

SYMPTOMS CONNECTED WITH THE TEGUMENTARY APPARATUS. 

The skin is hot and dry during the presence of fever. 

Moisture is almost always & favorable sign. 

The exceptions are, the profuse colliquative sweats of phthisis, etc., 
and the cold and clammy perspiration of extreme prostration. Cold- 
ness of the skin, or inequality of temperature, is always more or less 
unfavorable. 

Emaciation is often an important sign. It generally occurs in 
severe chronic diseases, but is sometimes rapidly brought on in acute 
affections ; e. g. diarrhoea or dysentery. The changes which occur in 
the adipose tissue, and in the plumpness and roundness, or flabbiness 
and shrunken appearance of the surface of the body, are often ex- 
tremely rapid in children. 

1 Microscopic examination has discovered (Schrceder von der Kolk) portions 
of disintegrated lung-tissue in the expectoration of phthisical patients j arched 
and anastomosing fibrils of pulmonary and bronchial elastic tissue. 

5* 



54 SEMEIOLOGY. 

The color of the skin varies much in disease. Thus, the face is 

Pale, in anaemia, syncope, etc. ; 

Flushed, in fever, congestion of brain, etc. 

Cheeks brightly flushed, in hectic fever; 

Forehead and eyes flushed, in early stage of yellow fever ; 

Purple or livid, in low continued fever ; 

Yellow, in jaundice, bilious fever, yellow fever; 

Sallow, in chlorosis, dyspepsia, cancer ; 

Blue, in the collapse of cholera, and in cyanosis ; 

Black, almost, in asphyxia. 
Eruptions upon the skin are characteristic of certain diseases. 
Their description belongs to Special Pathology. 

SYMPTOMS CONNECTED WITH THE SECRETIONS. 

These must always be considered along with other explanatory 
symptoms ; and the character of the discharges should never be 
overlooked. Thus, 
Constipation may denote — 

Torpor of the muscular coat of the bowels ; 

Deficient secretion of the liver, or intestinal glands ; 

Defective innervation, from spinal or encephalic disease ; 

Stricture of rectum or colon, pregnancy, or cancer; 

Intussusception, strangulated hernia, etc. ; 

Sympathetic disturbance from fever, etc. 
Diarrhoea and dysentery will be considered under another depart- 
ment. It may be mentioned, however, that in dysentery the discharges 
contain blood, mucus, lymph (in small quantity), and, when ulceration 
has occurred, pus. In diarrhoea they are either faecal, mucous, bilious, 
or serous — the latter being of importance especially in the diagnosis 
of cholera. 

Symptoms Connected with Urination. 

Dysuria, or difficult urination (strangury). 

Ischuria, retention of urine. 

Enuresis, incontinence. 

Diuresis (diabetes), excessive discharge of urine. 

Morbid character of the urine itself. 

The average quantity of urine passed by a healthy adult in twenty- 
four hours, is from thirty to forty ounces — greatest in the winter. 

In reaction to test-paper, the urine is normally acid; reddening 
litmus, or restoring to turmeric its yellow after it has been made 
brownish red by an alkali. 

The color of healthy urine is that of amber. 

The average specific gravity of human urine (water being 1000) is 
1017-20 ; containing about twenty grains of solid matter to the ounce. 

Deviation, to a certain extent, from any or all of the above stand- 
ards as to quantity, reaction, color, and weight, is quite compatible 
with ordinary health ; but a very decided and persistent deviation is a 
proof of disease. 



SYMPTOMS CONNECTED WITH THE SECRETIONS. 55 

Retention of urine may be caused by— 

Spasmodic constriction of the vesicourethral muscular fibres ; 
True stricture of the urethra ; 
Enlargement of the prostate gland ; 
Calculus in the bladder or urethra. 

Percussion and palpation, as well as catheterism, are sometimes 
necessary to determine the fact of retention of urine. 

Suppression of urine, from inaction of the kidneys, is a most seri- 
ous symptom under all circumstances. If long continued, it becomes 
fatal by urcemzc poisoning — coma, and often convulsions, preceding 
death. Partial suppression of urine occurs, sometimes transiently, in 
cholera, scarlet fever, etc. 

Excessive urination is frequently present in hysterical cases — the 
water being pellucid, and of low specific gravity (diabetes insipidus). 
The influence of cold and of diuretic medicines produces a similar 
watery excess, with little increase in the solids of the urine. 

Diabetes mellitus is, however, a more important affection ; in 
which the urine is not only excessive in quantity, but heavy, and 
loaded with sugar. 

For the accurate estimation of the changes occurring in the urine 
in disease, some scientific skill is requisite. To pursue original 
investigations upon the subject, considerable practical knowledge of 
analytical chemistry, and of the use of the microscope, is indispensa- 
ble. But for the application of the conclusions of pathological 
chemists and micrologists to diagnosis, a much more moderate 
amount of skill will suffice. There is wisdom in the remark of Dr. 
Todd [Clin. Led. on Urinary Organs, etc., p. 73), that, " while it is 
clearly a duty not to neglect any means of observation and investi- 
gation, it is desirable that you should be as little as possible dependent 
on means which are not always at hand, and which it does not fall to 
the lot of every eye and hand to use with equal readiness and skill." 

I shall state, on this principle, only the most important and availa- 
ble points in urinary pathology and diagnosis. 

Allowance must always be made, or correction obtained, for the 
variation the urine undergoes in the course of the same day. It is 
divided technically into the urina sanguinis, urina chyli, and urina 
potus; the first being that after a night's rest, the second that after 
dinner, the third after a very light meal with fluid, as tea. All of 
these should in each case be examined and compared. 

The questions in regard to any given specimen of urine are (see 
Bowman's Medical Chemistry), as to its general appearance, specific 
gravity, acidity or alkalinity, the chemical or microscopical charac- 
ter of its sediments, and the effect of reagents upon the clear fluid. 

General appearance. If clear, after standing a few hours, note 
the color. Deep-colored transparent urine, of high specific gravity, 
indicates excessive metamorphosis of tissue. In jaundice, the urine 
is generally very yellow, and sometimes as dark as porter. 

If the urine be opaque, it is either white or dark. White opaque 
urine contains either mucus, or pus, or undissolved earthy salts, or all 
of these together. Mucus floats more distinctly in a separate cloud 
than pus ; purulent urine is generally opaque throughout, and of a 
creamy yellow color at bottom. Pus can, however, be more readily 



56 SEMEIOLOGY. 

diffused by agitation than mucus. Purulent urine is oftenest acid ; 
mucous urine, generally alkaline. Pus contains albumen, as shown 
by testing ; mucus does not. Acetic acid coagulates mucus, not pus. 

Dark-colored opaque urine is most frequently tinged with blood, 
giving it a pinkish or brownish hue. The latter color prevails espe- 
cially in cases of passive hemorrhage from the kidney — the former, in 
fresh hemorrhage from the bladder, or acute renal hemorrhage. Urine 
may also be dark from the presence of bile (as in jaundice), or of pur- 
pur ine. 

For biliary coloring matter (biliphsein, cholepyrrhin) a good test is 
(Gmelin's) the addition of nitric acid, drop by drop, to a little of the 
urine on a white dish. It will become pale green, violet, pink, and 
yellow, in succession. Or (Heller's) shake a little solution of albumen 
(white of egg) with the urine, and then add a slight excess of nitric 
acid ; if bile be present, the coagulum will be dull green or bluish. 
Or (Ounisset), add half its bulk of chloroform to the urine ; the 
yellow coloring matter will be carried down. 

Pettenkofer's test for bile consists in the addition (after separating 
albumen, if it be present in the urine, by coagulation and filtration) 
to the fluid of a grain or two of white sugar, and then, drop by drop, 
two-thirds of the volume of strong sulphuric acid. If bile be present, 
a very distinct and characteristic violet-red color will be produced, 
which is intensified by heat. 

Purpurine is, probably, a morbid modification of the coloring 
matter of urine ; derived, originally, from that of the blood. Some 
pathologists believe it to be one of the indications of disease of the 
liver. It frequently accompanies deposits of urate of ammonia. 
Urine containing purpurine is pink or purple ; not unlike bloody urine 
in appearance. 

As tests, — liquor potassae makes purpurine greenish brown; car- 
bonate of potassa, yellow. Alcohol will dissolve purpurine from an 
evaporated extract of urine, receiving and retaining its color. Hy- 
drochloric acid, added to urine containing purpurine, will, if heat be 
applied, give it a lilac or decidedly purple tinge. 

The specific gravity of urine is easily ascertained by means of the 
urinometer ; a small glass instrument so marked that, when floated 
in the urine at 60° Fahr., it will show, in thousandths, the excess of 
density of it above that of water. 

Excessive weight of the urine is caused by its containing an unusual 
quantity of salts, or of urea ; or by sugar. The quantity passed in 
twenty-four hours must always be considered in connection with its 
specific gravity, so as to judge of the actual quantity of solids passed, 
as well as their degree of dilution. 

The heaviest urine is that of diabetes mellilus (glycosuria) ; some- 
times reaching 1060 or 1070. The lightest is observed in hysteria, and 
in Bright's disease ; running down sometimes even to 1003. 

The degree of acidity of urine may be approximately estimated by 
the more or less decided redness given by it to litmus paper. If it be 
alkaline, it will make turmeric brown, and restore the blue to litmus 
reddened by an acid. 

Alkalinity of the urine is uncommon ; unless (Bence Jones) im- 
mediately after a meal. If it does occur at other times, it depends 



SYMPTOMS CONNECTED WITH THE SECRETIONS. 57 

upon either fixed (potassa, soda) or volatile alkali (ammonia). If the 
former, it is usually associated "with nervous debility or general de- 
pression of vital power; except when accounted for by the medicinal 
use of potassa, soda, or lithia. Excess of the phosphatic salts, and of 
oxalate of lime (oxaluria), often accompanies alkalinity of the urine. 
The importance of the presence of oxalate of lime has probably been 
overrated. 

Carbonate of ammonia, when present in the urine, causes it to 
effervesce on the addition of an acid, from the escape of carbonic 
acid gas. The change of color produced by ammonia in turmeric 
paper will, also, disappear luhen it is heated. 

Ammoniated urine becomes so by the decomposition of urea, and 
its conversion into carbonate of ammonia. When the bladder is 
inflamed, and contains unhealthy mucus, this decomposition occurs, 
either in the bladder, or in the urine shortly after it is passed ; making 
it alkaline in reaction, and effervescent when acid is applied. In 
cases of much less frequency, urine will effervesce with acid from the 
presence of carbonate of lime. 

Sediments occur in the urine, either when first passed or after 
standing, from its containing substances (1) insoluble in it, or (2) pre- 
cipitated upon its cooling, or (3) from chemical changes rapidly taking 
place. Such sediments may be examined both chemically and micro- 
scopically. 

A fawn-colored deposit, not crystalline, which is redissolved ichen 
the urine is heated, consists of urates of ammonia and soda. Urate 
of ammonia is also immediately dissolved by solution of ammonia or 
of potassa. 

A much more rare deposit, of cystine, has a similar color ; but it is 
not soluble by heat, and is but slowly dissolved by alkalies. Cystine, 
under the microscope, shows rosette-like or hexagonal crystals, some- 
times like those of chloride of sodium ; the latter, however, is much 
the most soluble in water. The crystals of " triple phosphate" are 
known from those of cystine by being freely soluble in dilute acids. 

Heavy red sand, at the bottom of the vessel, insoluble in hydro- 
chloric acid, but dissolved by nitric acid, and also by alkalies (as 
liquor potassse), is uric (lithic) acid. When strong nitric acid is 
added to deep-red urine containing urate of ammonia in excess with 
purpurine, — solution occurs, with effervescence ; and a brownish de- 
posit falls, of uric acid chiefly. When evaporated to dryness, the 
addition of ammonia to the deposit will produce the purple murexide. 
Similar reactions occur with uric acid itself, acted upon by strong 
nitric acid. 

Blood-corpuscles sometimes fall to the bottom of urine as a colored 
sediment. They are not soluble in acids or alkalies, and may be dis- 
tinguished by aid of the microscope. 

A whitish deposit, not at all dissolved by heat, but dissolved by 
nitric acid, consists of earthy salts, phosphatic or oxalic. If oxalate 
of lime, it will not be dissolved by acetic acid ; if phosphates, that acid 
will render the liquid clear. Phosphatic deposits occur (even if not 
excessive in amount) when the urine is alkaline. Nevertheless, excess 
of the phosphates is indicated, by the urine becoming turbid when 
heated, and clearing up when acetic acid is added. 



58 SEMEIOLOGY. 

A creamy '-ivhite flocculent and ropy deposit, not dissolved on agi- 
tating the liquid, is probably mucus. A greenish-yellow settling, 
diffused when shaken, and which is dissolved by and forms & jelly with 
liquor potassae, may be concluded to be pus. 

The microscope may detect, even in urine scarcely opaque, or in 
its residue after evaporation, — 

Blood-corpuscles, disk-like, or jagged and out of shape ; 
Mucus-corpuscles, mingled with epithelial scales or cells ; 
Pus-corpuscles, granular, containing several nuclei ; 
Epithelial cells or scales, from the kidney or bladder ; 
Tubular casts from the kidney (desquamative nephritis) ; 
Spermatozoa ; thread-like, with one end ovate and expanded ; 
Uric acid crystals, variously shaped, as lozenges and square 

prisms ; 
Triple phosphate of magnesia and ammonia, in three-sided prisms 

with bevelled ends ; 
Phosphate of lime, granular, or in long needle-shaped crystals ; 
Oxalate of lime, in transparent octohedral or dumb-bell crystals ; 
Oil-globules (rare) with dark, smooth and well-defined outline ; 
Chyle-corpuscles, found in urine of a milky appearance. 
Urine free from deposit should, in suspected cases, be tested for 
albumen and for sugar. 

The test for albumen is the successive addition to the urine of heat 
and nitric acid. If it become and continue turbid under their com- 
bined influence, it is albuminous ; but neither alone will suffice. An- 
other test (Millon's) is the acid nitrate of mercury ; which causes with 
albuminous urine a pink precipitate. Fibrin and casein have this 
reaction also, but they will scarcely ever be found in urine, in the 
absence of albumen. Other mineral salts (ferro-cyanide of potassium, 
bichloride of mercury, &c, will precipitate albumen ; but the first-men- 
tioned test is the most available. 

We must remember, however, that albuminuria is no longer syno- 
nymous with Bright's disease. Albumen occurs, transiently, in the 
urine in many acute affections, as scarlatina, diphtheria, and renal 
congestion from cold and wet. It is only when persistent as a symp- 
tom that this becomes pathognomonic of degeneration of the kidney. 
In rare instances, moreover, this degeneration has been found (post- 
mortem) to exist, without albuminuria. 

The principal tests for diabetic sugar 1 (glucose) are Moore's, 
Trommer 's, Maumene"s, Bottger's, and fermentation. 

Moore's: Boil the liquid with half its bulk of liquor potassae. If 
saccharine, it will become first yellow and then brown, and ruby red 
by transmitted light. 

Trommer' s: Add a few drops of strong solution of sulphate of 
copper to the urine, in a test tube, and then pour in liquor potassae, 
to about half the bulk of the urine. On the careful application of 
heat, a yellowish or reddish-brown precipitate (sub-oxide of copper) 
is thrown down. 

Maumene's : Dip into the liquid a strip of flannel (not linen or mus- 

1 Bence Jones has found a very small quantity of grape sugar in healthy 
urine. 



SYMPTOMS CONNECTED WITH THE SECRETIONS. 59 

lin) saturated with a solution of bichloride of tin in twice its weight 
of water. The strip, on being heated over a fire or lamp to near 300° 
Fahr., will at once become brownish-black, like caramel. 

Bottger's : Add a few drops of dilute solution of nitrate of bismuth 
in nitric acid ; make the liquid alkaline with carbonate of soda, and 
boil for a few minutes. When sugar is present, it becomes dark, and 
will gradually throw down a grayish black deposit. If the urine were 
healthy a white deposit would fall. 

Fermentation, on the addition of yeast at 80° Fahr., will only occur 
in saccharine, not in ordinary urine. During this process, the white 
scum which forms is found, under the microscope, to contain the oval 
vesicles of torula which characterizes vinous fermentation. 

Trommer's test is the one most generally employed. Occasionally, 
a substance called alkapton may be present, which likewise reduces 
the oxide of copper ; but it will not ferment, nor cause a dark deposit 
with bismuth. Its possible existence does not interfere with the 
practical value of the test for sugar. 

Coloring matters taken as medicine or food may sometimes occur 
in the urine ; as rhubarb, senna, logwood, coffee, &c. Mineral acids 
will change the color of rhubarb or senna to a bright yellow. Aqua 
ammoniae will turn the orange hue of rhubarb to crimson. Indigo 
coloring matter (indican) is said to have been found in or educed 
from normal urine. 

The quantitative analysis of urine, to determine the amount and 
proportion of its different ingredients, requires considerable chemical 
proficiency. 

The following statement of the normal average amount of the 
constituents of healthy urine, passed in twenty-four hours, is from 
Thudichum : — 

grains. 



Solids, altogether 


. 850 to 


1020 


Urea 


. 463 to 


617 


Uric acid . 


. 


7.5 


Creatine . 


. 


4.5 


Creatinine 


. 


7.0 


Hippuric acid . 


. 


7.5 


Chloride of sodium . 


. 154 to 


200 


Sulphuric acid . 


23 to 


38 


Phosphoric acid 


.' 


56 


Earthy phosphates . 
Ammonia 


, , 


19 
10 


esides sarkine, urcematine 


uroxantine, potassc 


I-, soda, 



nesia, iron, trimethylamine, carbonic acid, phenylic acid, and dama- 
luric acid, in undetermined amounts. 

Heavy and dark-colored urine (diabetic urine is straw or amber 
colored), with a strong odor, may be inferred to contain an excess of 
solids from waste of tissue ; among which urea is the most important. 

When excess of urea is present, the addition of a few drops of 
strong colorless nitric acid to the urine on a watch-glass will throw 
down a number of crystals of nitrate of urea (delicate, rhomboidal, 
like those of saltpetre). 



60 SEMEIOLOGY. 

Excess of phosphates is generally associated with disintegration of 
brain and nerve tissue. 

Chloride of sodium has been found (Kedtenbacher) to disappear 
from the urine in the height of an attack of pneumonia, and (Beale) 
to appear at the same time in excess in the sputa. This maybe 
tested by the addition of a few drops of nitric acid, followed by solu- 
tion of nitrate of silver — a white precipitate of chloride of silver 
indicating the presence of the chloride of sodium. 1 

Fatty matter in the urine is detected by the microscope, and by the 
use of ether, which will dissolve the oily particles from the extract. 

Kyestein is a greasy pellicle found on the surface of the urine 
(after a day or two standing) of pregnant women, or (Kane) in those 
whose mammary glands are excited by sympathy with uterine irrita- 
tion. Urostealith is a solid adipose concretion (Roberts), now and 
then making part of a calculus. 

In a low state of vitality (Inman) the urine, after being passed, 
undergoes decomposition more rapidly than during health. 

For chemical analysis of urine by the student or practitioner, simple 
apparatus will answer. There are needed half a dozen test-tubes, a 
urinometer, a spirit-lamp, litmus and turmeric paper, and a small 
amount of each of the following reagents : nitric, hydrochloric, sul- 
phuric and acetic acids, liquor potassse, aqua ammonia, nitrate of 
silver solution ; and, sometimes, alcohol, solution of chloride of barium 
(to test for sulphuric acid or sulphates), and ether. 

Microscopical examinations may be made satisfactorily for ordinary 
purposes with an instrument of moderate cost ; such as Woodward's 
student's microscope. 2 (Guidance should be sought for in the works 
of Beale, Carpenter, Hogg, or Wythes on the microscope.) 

Urinary Calculi. 

Gravel, formed in the kidneys and passed, sometimes with much 
pain, along the ureters to the bladder, and thence out through the 
urethra, consists usually of urates of ammonia and soda, and uric 
acid. 

Calculi, of larger size, are in a majority of cases, composed of uric 
acid. Such are smooth or but slightly rough outside, formed in con- 
centric layers of different thickness. They will dissolve in a dilute 
solution of potash ; or in strong nitric acid, with effervescence. The 
microscope will show the uric acid crystals. 

Next in frequency is the calculus formed of a mixture of phosphate 
of lime with triple phosphate (of magnesia and ammonia), called/to- 
ble calculus ; because, before the blowpipe, it melts readily without 
combustion. 

Calculus of phosphate of lime is generally smooth and polished on 
the outside ; it chars before the blowpipe. So does the rather rare 
calculus of triple phosphate alone. 

Oxalate of lime forms the so-called mulberry calculus ; irregular 
and rugged in structure throughout. 

1 Chloride of ammonium will produce the same reaction j hut this salt is rare 
in the urine or sputa. 
3 Made hy J. W. Queen, Philada. 



SYMPTOMS CONNECTED WITH THE SECRETIONS. 61 

Cystine is occasionally found forming the substance of rather soft, 
brownish or greenish-yellow calculi. 

Uro-stealith has been already mentioned. 

Gall-Stones, 

These are concretions of biliary matter, formed in the gall-bladder, 
and frequently causing great pain in their passage along the cystic 
and common biliary ducts. They are of various sizes, averaging about 
that of a pea. Cholesterin forms the greater part of their substance, 
mixed with the biliary resinous and acid constituents (cholic and 
choleic acids, taurine, &c.) and coloring matter. 

From a solution of the gall-stone in boiling alcohol, cholesterin will 
crystallize, on cooling, in fine scaly crystals. Though allied to the 
fatty bodies, it differs from them in not dissolving in a solution of 
potash. The observations of Dr. A Flint, Jr., make it probable that 
cholesterin is converted normally into stercoral, in which form it is 
excreted. 

Other Secretions. 

The milk of a mother may'be affected in quality as well as quantity 
by the physical or even mental state of the individual ; so as to become 
innutritious, or even injurious to her offspring. 

In the parturient state, the sudden arrest of the formation of milk 
in the mammary gland, with the cessation of the uterine lochia! dis- 
charge, is an alarming symptom, — threatening child-bed fever. 

Menstruation is not exactly a secretion ; rather a periodical dis- 
charge of somewhat altered blood, along with monthly ovulation, or 
escape of a germ from the ovary. Its occurrence, however, is neces- 
sary to the health of the female, from 15 to 45 years, about, and its 
variations and deviations are important signs of disease. 

Abnormality in menstruation is, principally, either amenorrhcea, 
dysmenorrhea, or menorrhagia. The first, amenorrhcea, is either 
(1) non-appearance, (2) suppression, or (3) retention of the menses. 
The last of these (retention) is rare^ 

Suppression or irregularity of menstruation, apart from pregnancy, 
may result from uterine or ovarian disease, or from constitutional con- 
ditions affecting the uterus or ovaries functionally. The latter is more 
common in general practice. The amenorrhceal woman is generally, 
though not always, ancemic. 

Dysmenorrhoea (painful menstruation) may be either obstructive, 
spasmodic, or neuralgic. The first may occur from congenital small- 
ness of the orifice of the neck and mouth of the womb ; or, from 
retroversion, anteversion, or obliquity of that organ ; or pressure by 
a tumor ; or occlusion of the os by inflammatory bands or adhesions 
of lymph. The diagnosis of such affections from spasmodic or neu- 
ralgic dysmenorrhoea belongs to obstetric surgery or medicine. So 
does the consideration of retention of the menses. 

Perspiration.— Changes affecting the secretion of the skin have 
been already alluded to, in connection with the signs of disease be- 
6 • 



t>2 SEMEIOLOGY. 

longing to the tegument. Strong odor of the perspiration indicates 
vicarious excretion by the sweat-glands, and commonly accompanies 
insufficient action of the bowels. Acidity of the perspiration is some- 
times dependent on the presence of an excess of uric acid; which, in 
gout, in the form of urate of soda, is occasionally concreted palpably 
upon the surface of the body. Sudoric acid is said by Favre to take 
the place of uric acid, normally. The perspiration contains also 
chloride of sodium, urea, lactic acid, ammonia, &c. The odor of the 
perspiration is peculiar in smallpox, typhus, gout, albuminuria, &c. 

SYMPTOMS CONNECTED WITH THE MOTOR APPARATUS. 

The decubitus, or mode of lying down, of a patient, should be 
noticed. Inability to rise may depend upon general debility, paralysis 
of the extremities, rheumatic or gouty inflammation of the joints, etc., 
or injuries, such as fractures or dislocations. 

Inability to lie down is most frequently the result of dyspncea (or- 
thopnea) — the respiratory muscles having the freest scope in the erect 
position. 

In colic, the patient generally prefers to lie upon the belly. 

In peritonitis, the characteristic position is upon the back, with the 
knees drawn tip, to relax the abdominal muscles. 

Lying upon one side is often significant in disease. In the early 
stage of pleurisy, the patient prefers to lie upon the healthy side ; 
when effusion has taken place, this is reversed. In irritative disorder 
of the liver, with enlargement, the patient will often lie most com- 
fortably upon the right side. When the heart is enlarged or violent 
in its action, the sufferer generally cannot lie upon the left side. The 
exceptions are most frequent in cases of long duration. 

In aneurism of the aorta, the prone or semi-prone position (as lean- 
ing forward over a bed) is sometimes preferred. 

Muscular debility may be the result of acute disease, as fever, or 
of actual exhaustion and prostration. Total want of exercise will 
enfeeble the muscles ; as, when a limb is long confined in splints on 
account of a fracture or other injury. 

Spasm is of three kinds : tonic, clonic, and choreic. 

Tonic spasm is fixed rigidity ; such as emprosthotonos (arching of 
the body forwards) or opisthotonos (arching backwards) in tetanus. 
Clonic spasm is ordinary convulsion : i. e. successive contractions of 
the muscles at short intervals. Choreic spasm is a term suggested to 
indicate the jerking, irregular movement of the muscles, not control- 
lable by the will, in cases of chorea. 

Subsidtus tendinum, or jerking of the tendons at the wrist, is one 
of the symptoms of low states of continued fever. 

Paralysis will be alluded to presently. 



SYMPTOMS CONNECTED WITH SENSORY APPARATUS. 63 

SYMPTOMS CONNECTED WITH THE SENSORY APPARATUS. 

Of these, the most important is pain. Pain may be — 
Acute, sharp, cutting, as in pleurisy; 
Shooting, darting, as in neuralgia ; 
Lancinating, in cancer ; 
Gnawing, tearing, in rheumatism ; 
Dull, heavy, aching, in pneumonia; 
Griping, twisting, in dysentery ; 
Bearing down, in second stage of labor ; 
Pulsating, in the formation of an abscess ; 
Burning, smarting, in erysipelas ; 
Stinging, nettling, in urticaria ; 
Constant or intermittent ; fixed, or wandering. 
Tenderness on pressure is generally associated with inflammation; 
although some affections designated as neuralgic also present it — pos- 
sibly from inflammation of the sheaths of the nerves. Exhausted 
muscles also have it, with pain (myalgia, Inman). 

Sometimes pain is relieved by pressure ; as in many cases of colic 
and dysmenorrhea. This is a sign, usually, of the absence of in- 
flammation. 

Pain is not always at the seat of disease. Thus, in disease of the 
hip joint (morbus coxarius), the pain is felt chiefly at the knee ; in 
calculus of the bladder, at the glans penis ; in ovarian disease, some- 
times, along the limbs ; in disorder of the liver, often, under the sca- 
pula ; in dyspepsia, frequently, about the sternum ; and in irritation 
of the uterus, on the top of the head. 

Total loss of sensation, local or general, is called anaesthesia, 
Acinesia (a term seldom used) is loss of muscular power. 

Paralysis of one side only, of the body, e. g. the right arm and leg, 
is hemiplegia. Paralysis of both lower extremities, pa raplegia. These 
terms are commonly applied either to loss of power, loss of sensibility, 
or the more usual combination of both. 

The eye affords many indications of disease. A prominent and 
turgid condition of both eyes occurs in acute ophthalmia, and in con- 
gestion of the brain. If one eye alone becomes prominent, local dis- 
ease, e. g. a tumor behind the orbit, may be suspected. The eyes are 
sunken, in phthisis, and in other wasting maladies. Sinking of one 
eye indicates local atrophic disease. 

The movements of the eyes should be noticed, especially in children. 
Rolling of the eyeballs from side to side is a commom symptom of 
nervous restlessness or cerebral irritation in infants. Squinting, oc- 
curring as a symptom in disease, is of unfavorable import. 

The color of the eyes varies in disease. In conjunctivitis, the 
bloodvessels are generally enlarged, and the membrane reddened. In 
sclerotitis, the enlarged vessels are seen converging toward the margin 
of the cornea. In iritis, discoloration, irregularity, and sometimes 
fixedness of the pupil occur. 

The cornea in old people occasionally exhibits the arcus senilis — 
a sign of fatty degeneration. It is an opacity around the circum- 
ference of the cornea. 



64 SEMEIOLOGY. 

The lustre of the eye is lessened generally in depressing acute dis- 
eases, and especially just before death. 

The eyes are often remarkably bright during the progress of phthisis. 
They have a glare in some cases of inflammation of the brain, and of 
mania. 

The pupil is generally contracted in — 
Inflammation of the retina ; 
Inflammation of the brain ; 
Narcotism by opium, or the Calabar bean. 
It is dilated, usually, in — 

Apoplexy ; Amaurosis ; 

Hydrocephalus ; Cataract ; 

Narcotism by belladonna or stramonium. 
An immovable state of the pupil, or a difference between the two 
eyes under the same light, gives rise to suspicion of ophthalmic or 
cerebral disorder. 

Photophobia is a dread of or shrinking from the light, such as occurs 
in ophthalmia, and in meningitis or cerebritis. Other symptoms con- 
nected with the eye are — 
Pfiotopsia, flashes of light passing before the eyes. 
Muscce volitantes, moving spots, or spectra. 
Amblyopia, dimness of vision. 
Diplopia, double vision. 

Hemiopia, half-sight ; i. e. seeing but one-half of an object at a 
time. 

Tinnitus aurium, or ringing in the ears, may attend congestion of 
the brain ; nervous debility ; or quininization. Deafness may proceed 
from coryza (a cold in the head) ; wax in the ears ; quininization ; 
typhus or typhoid fever ; disease of the ear ; cerebral softening. 

Fain in the head (cephalalgia) may be specially alluded to as 
depending upon — 
Neuralgia ; 

Eheumatism of the scalp ; 
Congestion of the brain ; 
Toxaemia (e. g. by narcotics, alcohol, etc.) ; 
Fever (remittent, yellow, typhoid, etc.); 
Chronic disease of the brain ; 
Uterine irritation, etc. 
The distinction between these different forms of headache is by no 
means always easily made out. As a general statement, it may be 
said that neuralgic headache is mostly on one side (hemicrania), and 
extends more or less to the face ; it is usually accompanied, also, with 
sensitiveness of the scalp, and is shooting or darting in its character. 
Rheumatism of the head is attended by stiffness of the muscles which 
move the head from side to side. Congestive, febrile, and toxmmic 
headaches are accompanied by heat of the head, and are throbbing or 
pulsating. That of uterine irritation is on the top of the head. The 
pain of chronic cerebral disease (tumors, etc.) is commonly constant 
or periodic, in one spot, and is attended by some functional disorder. 



GENERAL VITAL CONDITION 65 



SYMPTOMS CONNECTED WITH THE PSYCHICAL APPARATUS. 

The expression of the countenance is usually altered by disease, 
especially of au acute kind. The change from anxiety or distress to 
serenity is always a favorable prognostic, except where gangrene, or 
paralytic anaesthesia accounts for it. 

Great anxiety of expression is seen especially in organic disease of 
the heart, and in acute disorders of the abdominal viscera. In hypo- 
chondriasis, a sad and desponding expression prevails. 

Terror is shown, by the countenance, in delirium tremens. 

Rage, in hydrophobia, and sometimes in acute mania. 

Insanity and imbecility, although not characterized by any special 
cast of counteuance, yet modify its expression so as to enable the 
mental state to be detected by one accustomed to the observation of 
deranged persons. 

The fades Hippocratica is the countenance of extreme exhaustion 
or of the moribund state. 

Delirium is described as being either active or passive. Active 
delirium is present in cases of acute meningitis ; passive or low mut- 
tering delirium, in typhus fever, etc. 

Coma presents itself in practice chiefly in four forms : Alcoholic 
stupefaction; Opium poisoning; Apoplexy; Typhus; also, fracture 
of the skull with compression of the brain. 

Typhous stupor is generally easy of recognition ; the others may 
give some trouble in the diagnosis. Between narcotism by opium and 
dead-drunkenness, we have the distinctions, that in opiate poisoning 
the pupil is almost always firmly contracted, and that the breath smells 
of alcohol (or aldehyde) in the intoxicated subject. 

GENERAL VITAL CONDITION. 

Lyons (Hospital Practice) remarks as follows : " The highest skill 
in physical diagnosis, and the most profound knowledge of patholo- 
gical anatomy, will leave you but very imperfect and unsafe practi- 
tioners, incapable of clear judgment and self-reliance in difficult cases 
in which you have to rest on your own responsibility, if you do not 
from the first endeavor to master and acquire for yourselves that un- 
written and indescribable knowledge which constitutes the consum- 
mate skill of the experienced medical man. It consists in a faculty of 
appreciating the vital state of your patient ; of forming a rapid but 
complete and accurate estimate of the nervous and muscular force 
which he possesses ; or, in general terms, of the powers of life which 
remain to him — his viability, so to speak, or the power which his 
system retains of resisting the morbid or fatal influences of injury or 
disease." 



6* 



66 SEMEIOLOGY. 



PHYSICAL DIAGNOSIS. 

The idea of physical exploration for the purpose of diagnosis has 
been well defined by Piorry, in the word " Organography :" i. e. the 
determination of the actual and relative position, material condition, 
and functional action of the organs contained within the body. The 
methods in use for this purpose are modern, dating from Auenbrugger, 
of Vienna, the inventor of diagnostic percussion, in 1761, and Laennec, 
the great originator of auscultation, about 1818. 

The modes of examination of the chest, abdomen, etc., are — 

Inspection ; Mensuration ; Palpation ; Succussion ; Spirometry ; 
Percussion; Auscultation. 

By inspection, we estimate, with the eye, the form, size, and move- 
ments of the chest, etc. 

By mensuration, we obtain a more accurate knowledge especially 
of deviations and alterations of size and form. 

Palpation aids in the determination of the character of surfaces 
and of subjacent parts, and, in the chest, detects changes in the de- 
gree or extent of the movements of respiration and of the heart, and 
in the vibrations connected with the voice, cough, and breathing. 

Succussion, or shaking the chest suddenly, is of use occasionally, 
in establishing the presence of fluid in the thoracic cavities. 

Spirometry is the measurement of the capacity of the lungs for 
air. 

By percussion we learn much of the physical condition of the 
lungs, heart, and abdominal viscera, through the variations of reso- 
nance and resistance when the walls of the thorax or abdomen are 
lightly struck. 

Auscultation is equally important, but somewhat more difficult in 
its application, on account of the complexity of the signs afforded by 
it. It consists in direct listening to the sounds produced within the 
cavities of the body, by placing the ear, with or without the stetho- 
scope, upon the surfaces thereof. 

The Regions of the Chest, for the purpose of physical exploration, 
may be most conveniently divided into the following : — 

ANTERIOR. POSTERIOR. 

Upper and lower sternal ; Interscapular ; 

Right and left clavicular ; Dorsal ; 

Eight and left subclavian ; Lower dorsal ; 

Right and left mammary ; Right and left acromial ; 

Right and left infra-mammary. Right and left scapular ; 

Right and left infra-scapular. 

LATERAL. 

Right and left axillary ; 
Right and left lateral ; 
Right and left lower lateral. 

The most important peculiarities of these different regions, in the 
normal state, are connected with percussion-resonance. The clearest 
and fullest sound, on percussion, is given over the subclavian and 



MENSURATION — PALPATION. 67 

lateral regions : the dullest and smallest, over the acromial, the right 
infra-mammary (hepatic), and the left mammary or precordial 

region. 

MENSURATION AND PALPATION. 

For mensuration, various stethometers or chest-measurers have 
been devised ; but, with care and judgment, the common tape-measure 
will suffice. 

The dimensions to be compared are the — 

Circular: around the chest opposite the base of the ensiform 
cartilage. This averages thirty-three inches. The right half of the 
thorax is nearly always half an inch to an inch larger in circumfe- 
rence than the left. 
Transverse : from the nipple to the middle of the sternum. 
Vertical : from the clavicle to the lower margin of the ribs. 
Antero-posterior : from the clavicle anteriorly to a corresponding 
point in the scapular region. 

General expansion and local bulging of the chest, and general re- 
traction and local depression, are the signs most frequently deter- 
mined by inspection and mensuration. 

General expansion or local bulging of the chest, usually upon 
one side only, may be caused by — 
Pleuritic effusion ; 
Pneumothorax : 
Emphysema of the lung; 
Aneurism, cancer, etc. : or. more rarely, by 
Hydrothorax ; 
Pneumonia ; 

Incipient tuberculization. 
Retraction or local depression of the thoracic walls may result 
from — 

Absorption of pleuritic effusion ; 
Tuberculization ; 
Pneumonia; 
Pleuro-pneumonia ; 
Infiltrated cancer of the lun°:. 



By palpation, we observe diminution of the expansion and 
elevation of the ribs in breathing, in — 

Pleurisy; Emphysema; 

Pneumonia; Intercostal rheumatism : 

Tuberculization ; Paralysis : 

Pneumothorax : Hydrothorax. 

Increased expansion and elevation of the ribs in breathing occurs 
in — 

Asthma ; 

Croup ; 

Spasm of the glottis ; 

Foreign bodies in air-passages. 



68 SEMEIOLOGY. 

Increased vibration of the walls of the chest with the voice and 
COUgh is noticed in — 

Tuberculization ; Pulmonary apoplexy ; 

Pneumonia ; Dilatation of bronchi. 

Diminished vocal and tussive vibration occurs in — 

Pleuritic effusion ; Emphysema ; 

Pneumothorax ; Cancer of the lung. 

Rhonchal vibration, occasionally, in bronchitis. 
Rubbing, or to-and-fro vibration, in — 

Pleurisy ; Pericarditis. 

Pulsatile vibration in — 

Aneurism of aorta ; 

Cancer of lung or pleura ; 

Pneumonia. 
Fluctuation in— 

Large pleuritic effusion. 
Purring vibration (frSmissement cataire) in — 

Aneurism of aorta ; 

Valvular heart disease ; 

Anaemia. 

SPIROMETRY. 

For Spirometry, Hutchinson's, Pereira's, Coxeter's, and Mitchell's 1 
spirometers have been used. 

Dr. Hutchinson made elaborate investigations into the comparative 
breathing power of individuals, by which he proposed to conclude 
upon their vital capacity. A man 5 feet 8 inches in height, and of 
155 pounds weight, was found, on the average, to expire, after a full 
inspiration, 230 cubic inches. 

For every inch of height above this, a definite increase in the 
quantity breathed was observed. The proportion was less constant 
with weight and with age. After fifty-five there was a decrease. 

In the first stage of consumption, the average (for the adult of 
ordinary height) was found to be 154 cubic inches ; second stage, 131 ; 
late stage, 108, etc. 

In practice, however, spirometry is not extensively used. 

PERCUSSION. 

Percussion is either mediate or immediate. In immediate percus- 
sion, we tap with the ends of the fingers at once upon the body ; in 
mediate percussion, a pleximeter (stroke-measurer) is used. The 
latter is almost universal; but a difference exists as to the kind of 
pleximeter employed. Louis and Walshe prefer one made of caout- 
chouc ; Piorry and Skoda, one of ivory ; Wunderlich uses an ivory 
disk, upon which he strikes with a small steel hammer, the head of 
which is covered with caoutchouc. 

A majority of practitioners, however, are satisfied (with good rea- 
son) with the use of the middle finger of the left hand as a pleximeter. 

1 Consisting of a small gas-meter y with a mouth-piece. 



PERCUSSION. G9 

(Percuss by movement of the hand on the wrist ; not by sledge-ham- 
mer motion from the shoulder). 

In using percussion as a means of physical diagnosis, we note — 

1. The clearness or dulness of the resonance produced. 

2. The duration of the resonance. 

3. Its special character, 

4. The degree of resistance felt. 

Certain terms are in common use to describe particular characters 
of resonance: as, wooden sound, thigh sound, stomach sound, tympa- 
nitic or drum-like resonance, amphoric or pitcher-like sound, bruit 
de potfele or cracked-pot sound, etc. 

It is indispensable, in commencing the study of percussion (or other 
modes of physical diagnosis), to become familiar with the normal and 
natural sounds observed in health. To be anything more than a rou- 
tine diagnostician, moreover, it is necessary to understand the prin- 
ciple of the exploration, and as far as possible, the reason of the 
meaning of every sign. 

Two or three very simple facts explain the use of percussion in 
diagnosis. 

When any solid body is struck, the sound elicited varies according 
to its material, form, size, and. if holloic, the condition of its walls, 
and that of its contents. 

The human thorax (or abdomen) having a certain general form, size, 
condition of its walls, and proportion of air. blood, and solid struc- 
ture in its contents, will give forth a certain degree and kind of reso- 
nance. 

Whatever alters either the state of its u-alls or the proportion of 
air. fluid, and solid contained within them, gives rise to an alteration 
of percussion-resonance. 

Alteration of the state of the walls of the thorax seldom occurs 
in disease in such a way as to modify percussion-resonance. Changes 
in the proportion of solid, liquid, and air, in the lungs and pleural 
cavities, as well as in the similar relations of the heart and pericar- 
dium, aorta, etc., are frequent. The more air. and the less liquid or 
solid contained within the part of the chest which is percussed, the 
clearer and fuller the resonance, and, as a general rule, the less the 
resistance to the finger. Any increase in the relative proportion 
of liquid (as in pleuritic effusion), or of solid (as in tuberculization), 
must cause a duller or lesser degree of resonance, and, other things 
being equal, a greater degree of resistance. 

Thus, diminution of clearness and duration of the percussion- 
sound, with increased resistance of the walls of the chest, occurs 
in — 

Pneumonia ; Pulmonary apoplexy ; 

Pleu risy ; Hy d r oth orax ; 

Tuberculization ; Cancer, etc. ; 

Collapse of lung. 

The extent over which dulness on percussion is observed sometimes 
varies with the position of the patient. This is practically important 
in the diagnosis of pleuritic effusion, empyema, hydrothorax, and 
hydrop n e u m oth o ra x. 



70 SEMEIOLOGY. 

Increased clearness and duration of resonance, with decrease of 
resistance, occurs in— 

Pneumothorax ; Emphysema ; 

Atrophy of lung; Anaemia ; 

Hypertrophy of lung ; Emaciation. 

Increased clearness of sound with increase of resistance is ob- 
served when there is a tubercular cavity near the surface of the chest, 
with its outer wall thin, hard, and adherent to the pleura. 
Tympanitic resonance of the chest is present in — 
Pneumothorax ; 
Emphysema ; 
Pulmonary atrophy, etc. 
Amphoric resonance, when there is a large tubercular cavity, with 
solid and tense walls, near the surface of the chest. 

The cracked-pot sound indicates an anfractuous cavity, i. e. one 
whose walls are broken or incomplete, communicating with the bron- 
chial tubes. It may be imitated by clasping the hands loosely and 
then striking the back of one of them upon the knee. 

Skodd's classification of percussion-sounds has the merit of great 
simplicity. . He distinguishes them as 

Full ; empty ; (large and small resonance) ; 
Clear ; dull ; 

Tj 7 mpanitic ; non-tympanitic ; 
High ; low ; (pitch). 
A sound may be at the same time full and dull, or clear and empty 
(small). 

Skoda does not value very highly the information obtained from 
differences in the pitch of percussion sounds. Other authorities dif- 
fer from him, however, upon this point ; and with good reason. 

AUSCULTATION. 

In auscultation, as well as in percussion and other modes of physi- 
cal exploration, a comparison is made not only with the normal stand- 
ard, but between the two sides of the chest. 

The stethoscope is, in auscultation, generally speaking, a superfluous 
instrument. If any be used, a simple wooden tube with one end 
slightly expanded is the best. Camman's double stethoscope is approved 
by Dr. Flint; but it requires a good deal of practice to use it well. 

The beginner must familiarize himself with the natural breathing 
sound, as heard when the ear is placed over any part of the lungs, 
and with that heard in the sternal and inter-scapular regions. The 
latter is bronchial, the former is the vesicular murmur. The tubu- 
lar, blowing character of the respiration, as heard in the bronchi, and 
its soft, breezy nature when the ear is placed over the lungs, are es- 
sential elements in diagnosis by auscultation. 

The pulmonary vesicular murmur is always louder in infants and 
children. Puerile respiration is, therefore, the name given to exag- 
gerated breathing-sound in the adult. 

In a healthy state of the lungs, the expiratory murmur is very 
faintly heard. A prolongation, and increase in loudness, of the sound 
of expiration, is sometimes a sign of disease (tuberculization). 



AUSCULTATION. 11 

The sounds detected by auscultation of the chest are divided into 
respiratory and secretory sounds, friction sounds, and modifications 
of vocal resonance. 

Respiratory Sounds. 

Normal vesicular murmur ; 
Puerile respiration ; 
Prolonged expiratory sound ; 
Harsh, tubular, blowing, 
Bronchial, and cavernous respiration ; 
Amphoric respiration. 

Secretory Sounds. 

Dry. 

Sibilant rhonchus (hissing or whistling) ; 
Sonorous rhonchus ; 
Dry crackle. 

Moist. 

Fine crepitation or crepitant rale ; 
Coarse crepitant rale (mucous rale) ; 
Humid crackle or gurgling ; 
Metallic tinkling or dropping sound. 
Friction-sounds are peculiar to pleurisy and pericarditis, at the 
stage of adhesion, or, at least, of effusion of plastic lymph. 
Modifications of vocal resonance are — 
Bronchophony ; 
Pectoriloquy ; 
JEgophony. 
The above is. essentially, the classification commonly adopted by 
auscultators. That of Skoda is, however, still more simple. He di- 
vides respiratory sounds into 

Vesicular ; Amphoric ; 

Bronchial ; Indeterminate. 

Skoda denies, also, the validity of the distinction between pectori- 
loquy and bronchophony ; and shows that wgophony cannot have 
the precision of meaning supposed by Laennec and others to belong 
to it. 

No description of the sounds of auscultation can do more than 
guide and assist their actual clinical study. For this purpose the 
simplest and clearest terms are, of course, the best. 

The normal respiratory murmur as heard in the lungs, is well 
illustrated by Skoda as resembling (during inspiration) the sound 
caused by narrowing the opening of the mouth, and then drawing in 
the air. The consonant of this murmur is / or p. The expiratory 
murmur may be represented as somewhere between/ and h. That of 
the larynx, trachea, and bronchi, by the guttural ch, or between that 
and h. The vesicular murmur is slightly louder (Flint) and lower in 
pitch, on the left side. 
By bronchial respiration as a sign of disease in the lung, we mean 



72 SEMEIOLOGY. 

a breathing-sound heard while listening over the lung, like that nor 
mally heard when auscultating the middle regions of the chest, over 
the bronchial tube. It occurs when the lung is solidified or condensed. 
(The explanation of bronchial respiration is by conduction or by con- 
sonance. The latter theory, that of Skoda, is preferred.) 

Cavernous respiration is that which is inferred to occur during the 
passage of air into or out of a cavity in the lung (as in tubercular dis- 
ease). Notwithstanding the truth of the statement urged by Skoda, 
that it is often impossible to draw a certain demarcation between 
bronchial and cavernous respiration, yet, in a sufficient number of cases 
this can be done, and the term cavernous, therefore, should be re- 
tained. 

Of the secretory sounds, the sibilant and sonorous rhonchi are 
the results of narrowing and obstruction, by congestion, mucus, etc. 
of the bronchial ramules ; the smallest, in the case of the sibilant or 
whistling rhonchus; those somewhat larger, so that the air passes 
through in irregular and varying bubbles, in the sonorous (snoring or 
roaring) rhonchus. Both of these sounds are characteristic of bron- 
chitis. The use of the term dry sounds, as applied to them, is not 
strictly correct ; but it is convenient, as designating the impression 
which they convey to the ear as compared with those technically 
called moist sounds. 

The dry crackle is associated with incipient or infiltrated tubercle. 

Among the moist sounds, the finest or most delicate is the crepi- 
tant rale, or fine crepitation, of pneumonia. It is very well imitated 
by rubbing a few hairs of one's head between the thumb and finger, 
near the ear. Its cause is, probably, the penetration of the air into 
the air-cells of the lung at a time when their walls are rendered 
slightly adhesive by effusion of cpagulable lymph. The gentle forcing 
apart of these adherent walls, or of portions of the viscid lymph 
itself, produces the fine crackling sound, as a modification of the 
natural vesicular murmur. It is only heard during inspiration. 

Coarse crepitant or " mucous" rales are heard whenever any fluid 
exists in the lungs in quantity sufficient to modify respiration without 
arresting it, whether that fluid be mucus, pus, blood, or serous effusion. 

The humid crackle or gurgling is pathognomonic of advanced 
tuberculization. It is heard during the later stages of nearly all cases 
of consumption. 

Friction or to-and-fro sounds are produced by the rubbing of two 
surfaces, as of the pleura or pericardium, when made adherent or 
slightly roughened by inflammatory lymph. It sometimes requires 
an acute and practised ear to discriminate these from other sounds. 
They are heard both with inspiration and expiration. 

Bronchophony, or bronchial vocal resonance, corresponds in its 
history with bronchial respiration. It is simply a resonance of the 
voice, to the ear of the auscultator placed over the lung of the patient 
while he speaks, loud, near, and clear, as it is normally when the ear 
is placed over the bronchial tube. The same reasonings will apply 
to the explanation of this sign by the two theories of conduction and 
consonance, which have been urged in regard to bronchial respiration. 
The latter theory, as in that instance, I prefer ; but, practically, all 
agree as to the circumstances under which the sign occurs (solidifica- 



AUSCULTATION. 73 

tion of the lung). Normally, the vocal resonance is loudest under 
the right scapula. Modifications of the sound of the whispered voice 
are spoken of by Dr. Flint as exaggerated bronchial, amphoric, and 
cavernous whisper. 

Pectoriloquy (chest speaking) is merely a yet nearer and louder 
resonance of the voice, heard on auscultation, than that called bron- 
chophony ; the sound seeming to be vocalized in that part of the lung 
which is immediately under the ear. Skoda objects that this cannot 
be definitely distinguished from loud bronchophony. But, although 
this is generally true, a certain number of cases occur in which it 
may be so distinguished, as indicative of a very different pathological 
state of the lungs, viz., a large cavity. 

Aegophony, bleating, or goat-like resonance of the voice, has been, 
since Laennec, supposed to be an almost certain sign of the existence 
of pleuritic effusion or hydrothorax. Skoda' s observations, and those 
of others also, show that it is occasionally heard in pneumonia, in 
phthisis, and even in the healthy state of the thoracic ^organs. It is, 
therefore, not pathognomonic of the presence of fluid within the pleura ; 
but it is among the signs which render that diagnosis probable. 

Amphoric resonance is heard especially in connection with the 
sound produced by coughing. A tense condition of the walls of a large 
cavity will explain it, as well as the phenomenon called metallic echo 
of the voice or cough. 

Metallic tinkling is usually accounted for by the dropping of fluid 
in a large cavity (as in hydropneumothorax, with collapsed lung) with 
tense walls. 

Resuming the consideration of respiratory sounds, puerile or exag- 
gerated respiration occurs in the healthy lung, or part of the lung, 
when the other lung or portion of the same is obstructed, as by a for- 
eign body, or by bronchitis ; condensed, as by 

Pneumonia ; Pleuritic effusion ; 

Tuberculization ; Tumor. 

A lung, a portion of which is permanently expanded by emphysema, 
or hypertrophied, may also give an exaggerated vesicular murmur ; 
and, transiently, this is observed in a lung fust released from the 
paroxysmal obstruction of asthma. 

Feeble respiratory murmur is heard in one or both lungs in cases of 
Croup ; Collapse of lung ; 

Foreign bodies in air-passages ; Pulmonary apoplexy ; 
Bronchitis ; Emphysema ; 

Pneumonia; Pneumothorax; 

Pleurisy; Hydrothorax ; 

Asthma ; Intercostal rheumatism ; 

Infiltrated tubercle ; Paralysis ; 

Cancer ; or other tumor. 
Harsh respiratory murmur, passing by gradations into blowing 
and bronchial, in 

Dry bronchitis ; Pneumonia ; 

Incipient tubercle ; Pulmonary apoplexy ; 

Pleurisy (condensing lung); Bronchial dilatation. 

7 



74 SEMEIOLOGY, 

Cavernous respiration, in case of 
Tubercular cavity ; 
Excavation from 
Abscess of lung ; Softening of cancer ; 

Gangrene ; Large bronchial dilatation. 

Amphoric respiratory sound is particularly associated with the 
existence of a fistulous opening between the pleural cavity and one 
of the bronchial tubes ; the cause of which fistula may be either tuber- 
culous softening, or abscess, etc. 

The sibilant and sonorous rhonchi occur nearly always in bron- 
chitis ; occasionally in pulmonary emphysema, and when the bronchi 
are pressed upon by tumors, etc. 
Dry crackling indicates the existence of hard tubercle in the lungs. 
Humid crackling or gurgling, tubercle in the softened state. 
The crepitant rale has already been explained as peculiar to pneu- 
monia. 

The coarse crepitant 1 rale, or mucous rale, is observed frequently in 
Capillary bronchitis / Pulmonary hemorrhage ; 

Bronchorrhea ; Pulmonary oedema ; 

Last stage of pneumonia ; Pulmonary abscess. 

Friction sounds have been before alluded to as connected with 
pleurisy and pericarditis. 
Resonance of the voice is feeble in 

Emphysema; Atrophy of the lung; Pneumothorax. 
Bronchophony occurs in case of 
Tubercle ; 

Hepatization (pneumonia) ; 
Pleurisy (condensing lung) ; Cancer ; 
Dilatation of bronchi. 
Aegophony, in 

Pleurisy ; Hydrothorax ; Pneumonia. 
Pectoriloquy, in case of 
Tubercular cavity ; 
Dilatation of bronchi ; 
Excavation from 

Abscess ; Cancer ; Gangrene. 
Metallic tinkling and echo, in 
Pneumohydrothorax ; 
Large tubercular cavity. 
The sounds of the heart are heard at an unusual distance from 
the heart itself, in some cases of 

Pneumonia ; Pleurisy ; 

Tubercle; Cancer, etc. 

(This affords some argument for the conduction theory of Laennec.) 

Displacement of the heart, diaphragm, liver, spleen, stomach, 
sometimes occurs from pleuritic effusion or empyema, cancer of the 
lung, etc. In rare instances, such a displacement may be congenital ; 
as of the heart on the right side side. 

1 The term $w£-crepitant r&le or rhonchus, appears to the author to be very 
objectionable, as leading to confusion. 



AUSCULTATION — HEART. 75 

Diseases of the Heart. 

The physical diagnosis of diseases of the heart is conducted upon 
exactly the same principles as that of affections of the lungs and pleura. 

By inspection we can detect bulging or distortion in the precordial 
region, and, in some cases, judge of the extent, force, and character 
of the heart's impulse. By mensuration, changes in the thoracic 
dimensions consequent upon diseases of the heart can be more accu- 
rately determined. 

By palpation, the impulse of the heart may always be examined 
and estimated. This is very important, not only in actual diseases of 
the heart, but also in fevers, etc. ; in the course of which the move- 
ments of the heart, as the centre of the circulation, are often seriously 
affected. 

In hypertrophy, this impulse is increased in force ; in dilatation, it 
is extended ; in atrophy, it is diminished. 

Percussion aids us in detecting some very important pathological 
changes in the heart ; as hypertrophy, dilatation, pericardiac effu- 
sion. The percussion resonance is unusually clear in atrophy of the 
heart. 

In auscultation of the heart there is often a convenience, although 
no necessity, in the use of the stethoscope. The learner must in the 
first place make himself familiar with the natural sounds of the heart. 

The first sound is the longest and loudest ; the succession being 
imitated by the syllables lubb, dup. If the time from the commence- 
ment of one pulsation to that of another be divided into five equal 
parts, two of them will be occupied by the first sound, one by the 
second, and two by the interval of repose. 

The first sound accompanies the systole or contraction of the ven- 
tricles ; the impulse of the heart occurs at the same moment. The 
second sound is diastolic as regards the ventricles. 

The causes of the first sound are believed to be the contraction of 
the powerful ventricular muscles, the tension of the closed auriculo- 
ventricular valves, the rush of blood into the great vessels, and the 
impulse of the heart against the walls of the chest. 

The cause of the second sound has been proved to be the flapping 
together, during the diastole or dilatation of the ventricles, of the 
pocket-like, semilunar valves of the aorta and pulmonary artery. 

The essential points in the " medical anatomy" of the heart are as 
follows : — 

The semilunar valves of the pulmonary artery lie behind the 
junction of the cartilage of the third rib with the sternum. 

The semilunar valves of the aorta are just below these, between 
the cartilages of the third and fourth ribs. 

The tricuspid or right auriculo-ventricular valve is behind the 
sternum, on a level with its articulation with the fourth rib. 

The mitral or left auriculo-ventricular valve lies behind the carti- 
lage of the fourth rib, a little to the left of the sternum. 

The heart's apex strikes, during the impulse, at a point just below 
and outside of the left nipple. The point of greatest dulness on per- 
cussion is slightly within the left nipple. The diameter of the normal 
region of dulness does not exceed two inches. 



T6 SEMEIOLOGY. 

Using terms of convenience merely, the valves of the heart may be 
said to be of two kinds ; cavity valves and vascular valves. The 
cavity valves are both nearer to the middle and apex than to the base 
of the heart; the vascular valves (aortic and pulmonary arterial) 
nearer to its base, i. e. as the heart is situated in the chest, its upper 
part. 

By auscultation of the heart we may detect valvular murmurs, 
anaemic murmurs, and friction sounds. Details in regard to these 
can be best given in connection with the special pathology of the heart. 
A few main points only require mention here. 

The valves of the left or systemic portion of the heart are much 
more often affected by disease than those of the right. Practically, 
in most cases, those of the right side may be left out of the question 
of diagnosis. 

The following is Harvey's statement of the comparative frequency 
of the different valvular affections : — 

1. Aortic obstructive. 

2. Mitral regurgitant. 
3 Aortic regurgitant. 

4. Aortic obstructive and mitral regurgitant together. 

5. Aortic obstructive and regurgitant together. 

If a murmur (not anaemic) is systolic, i. e. is heard with the first 
sound of the heart, and is loudest at the base of the heart, it may be 
inferred to be aortic obstructive. 

If systolic, and loudest at the apex, mitral regurgitant. 

If diastolic, i- e. with the second sound, and loudest at the base of 
the heart, aortic regurgitant. 

If diastolic, and loudest at the apex, mitral obstructive. 

The rationale of these inferences is explained by the physiology of 
the heart's action, in connection with the position of the several valves. 

Much complexity attaches necessarily to the exact diagnosis of 
affections of the heart ; but we have the excellent authority of Dr. 
Stokes for the principle, that the important practical questions in 
each case are — do the abnormal sounds present have origin in organic 
disease or lesion, or not ? and, how far is the functional action and 
capacity of the heart interfered with or impaired ? 

Upon these, as upon all other questions in diagnosis, it is proper 
never to confine our attention to physical or immediate signs alone. 
To rest either upon symptomatology or physical exploration exclu- 
sively, would be like hopping constantly on one foot, instead of walk- 
ing upon two. 

Friction sounds, in the region of the heart, are connected with 
pericarditis. Their narrow limits, and association, in time, with the 
sounds of the heart, serve usually to contrast them with pleuritic 
sounds. It is sometimes difficult to distinguish them from valvular 
murmurs. 

The signs of aneurism of the thoracic aorta may be alluded to in 
another place. They are, chiefly: 1. A second impulse (often with a 
thrill), apart from that of the heart. 2. Dulness on percussion. 3. 
Bulging. 4. Symptoms of dyspnoea, cough, and dysphagia, from 
pressure upon the trachea, oesophagus, etc. 



LARYNGOSCOPY. 77 

Abdominal Diseases. 

The physical diagnosis of abdominal affections comprises inspec- 
tion, mensuration, palpation, percussion, and auscultation. The belly 
is divided, externally, into the epigastric, umbilical, hypogastric, two 
hypochondriac, two lumbar, and two iliac regions. 

By abdominal inspection we can observe the alteration in size and 
shape caused by pregnancy, hernia, tympanites, ascites, or ovarian 
dropsy. By mensuration, we can ascertain the exact changes which 
may occur from time to time in dropsical accumulations, etc. 

By palpation of the abdomen, we may develop the symptom of 
local tenderness on pressure: as in gastritis, hepatitis, peritonitis, 
cystitis, etc. By the same method of examination, more forcibly em- 
ployed, we detect enlargement of the liver or spleen, ovarian tumor, 
mesenteric disease, cancer, aneurism, f cecal accumulation, etc.; and, 
with the aid of both hands, prove the presence of fluid (ascites, etc.) 
by the sign of fluctuation. 

Percussion assists materially in the diagnosis of diseases of the 
abdominal viscera. The ordinary percussion-resonance, in health, is 
clear, full, and slightly tympanitic, all over the abdomen. It becomes 
more drum-like in distension of the intestines with gas (meteorism), 
or in tympanitic distension of the peritoneum. Dulness of resonance 
occurs, with limits and peculiar characters, in enlargement of the liver 
or spleen, ascites, ovarian dropsy, pregnancy, cancer, aneurism, re- 
tention of urine, f cecal accumulation, etc. 

Auscultation of the abdomen is especially useful in the diagnosis 
of pregnancy, by detecting the sounds of the foetal heart, and the 
placental soufflet. 

Morbid sounds are occasionally appreciable in abdominal affections, 
as in tape-worm, etc. ; but they are subject to so much uncertainty as 
to be hardly available for practical purposes. Friction-sounds in 
peritonitis have recently been studied by Dr. Seidel. 

The Laryngoscope. 

Instrumental aid in examining the interior of the larynx was first 
thought of by Levret, in 1743. Laryngoscopic mirrors were devised 
by Dr. Babington, of London, in 1829. Tlirck, of Vienna, applied 
them anew to diagnosis in 1857 ; but shortly afterwards Czermak pur- 
sued laryngoscopy with so much acuteness and energy as to have 
associated his name with it pre-eminently. 

The apparatus required, (Semeleder) is a laryngeal mirror, an illu- 
minating mirror, and a tongue-depressor. Glass or polished metal 
may do for the mirrors. 

The laryngeal mirror may be round or square, preferably the 
former ; and about an inch or less in diameter. It should be attached 
at an obtuse angle (120° to 125°) to a stem, which may be fastened 
into a slender handle so as to be drawn out or pushed in. 

The illuminating mirror is larger (from 3 to 12 inches in diameter) 
and concave, to concentrate reflected light. It may be held by a 
handle in the operator's mouth, or fixed by a band to his forehead, or, 
best, as used by Semeleder, perforated in the middle and fastened to 

7* 



78 SEMEIOLOGY. 

the bridge of a pair of spectacles (with or without the glasses) so 
as to rest before one of the eyes and be looked through. 

The laryngeal mirror is introduced (after being warmed to prevent 
condensation of moisture) so that its back pushes the uvula upwards 
and backwards, its lower edge presses upon the posterior wall of the 
pharynx, and its stem rests in the angle of the mouth. 

Sunlight, horizontal (morning or evening), is the best for laryngo- 
scopy, but artificial light, as of a good lamp, may suffice. 

The difficulty of the operation is produced by the irritability of the 
fauces and larynx. Few can allow of a successful examination on the 
first attempt ; practice makes tolerance. To hasten this, bromide of 
potassium has been given by some. The frequent insertion, and re- 
tention for a while, of the finger of the patient, or of an instrument 
in the fauces, accustoms the parts to pressure. Holding ice in the 
throat, just before the examination, also lulls sensibility. 

By laryngoscopy, tumors, ulcerations, inflammatory changes, etc., 
in the larynx may be inspected, topical applications, as of nitrate of 
silver (H. Green) made, and surgical operations performed, with a 
precision not otherwise possible. 

Rhinoscopy is the examination, in a similar manner, of the poste- 
rior nares. It requires merely a smaller mirror (less than three- 
fourths of an inch diameter) than for laryngoscopy, and at about a 
right angle to its handle. 

The ophthalmoscope (for the eye), otoscope (for the ear), endo- 
scope (fo\r the urethra), uterine speculum, etc., are instruments for 
surgical and obstetric diagnosis, not demanding description here. 

TEMPERATURE IN DISEASE. 

The thermometer (De Haen, 1754, Wunderlich, J. Davy) is a use- 
ful aid in diagnosis and prognosis ; making exact that information 
which every physician constantly obtains by the touch. It is espe- 
cially valuable in the chemical study of febrile disorders ; as, since 
Galen, fever is essentially defined by the words " preternatural heat." 

The axilla is the best part for examination of temperature. The 
instrument should be kept there from three to five minutes at a time. 
Normally, in the armpit, the temperature averages 98.4° Fahr. ; with 
a range in health (Davy) from 99° to 97.92°. It is about 1° higher 
in tropical than in temperate climates. In the temperate it is highest 
on waking in the early morning ; lowest at midnight. In tropical re- 
gions, it is lowest in the early morning, and highest during the day. 1 
It is one or two degrees higher in children than in adults. 

A rise of temperature, in disease, of 1° Fahr. corresponds, as a rule, 
with an increase of the pulse, of eight to ten beats per minute. The 
thermometer in the axilla may, in some febrile cases, mark 106°, 108°, 
even 112°. It has been found highest in scarlet fever, yellow fever 
(Dowler) and tetanus. Dr. H. C. Wood, Jr., found it 109° in the 
axilla of a man dying with heat-stroke ; and 110| in his abdomen after 
death. 

1 See Aitken's Science and Practice of Medicine, 4th ed., vol. i. p. 39. 



TEMPERATURE IN DISEASE. T9 

In intermittent fever, during the paroxysm, even when the patient 
shivers and feels cold to himself, his heat by the thermometer is always 
above the natural degree. 

1 " When the temperature is increased beyond 98.5° it merely shows 
that the individual is ill ; when it is raised as high as 101°-105°, the 
febrile phenomena are severe ; if above 105°, the patient is in immi- 
nent danger ; with 108° or 109°, a fatal issue may without doubt be 
expected in a comparatively short time. 

A person, yesterday healthy, who exhibits this morning a tempera- 
ture above 104° Fahr., is almost certainly the subject of an attack of 
ephemeral fever or of ague ; should the temperature rise to or beyond 
106.3°, the case will certainly turn out one of some form of malarious 
fever. It cannot be typhoid fever. 

A patient whose temperature rises during the first day of illness 
up to 105° or 106° Fahr., certainly does not suffer from typhus or 
typhoid fever. In a patient who exhibits the general typical signs of 
pneumonia, but whose temperature never reaches 101.7° Fahr., it may 
be concluded that no soft infiltrating exudation is present in the lung. 

If a patient suffer from measles, and retains a high temperature 
after the eruption has faded, it may be concluded that some compli- 
cating disturbance is present. 

In typhoid fever a temperature which does not exceed any evening 
103.5° indicates a probably mild course of the fever. 105° in the 
evening, or 104° in the morning, shows danger, in the third week. In 
pneumonia, a temperature of 104° and upwards indicates a severe 
attack. In acute rheumatism a temperature of 104° is always an 
alarming symptom, foreboding danger, or some complication such as 
pericardial inflammation. In jaundice, otherwise mild, a rise of tem- 
perature indicates a pernicious turn. In a puerperal female an increase 
of temperature shows approaching pelvic inflammation. In tubercu- 
losis an increase of temperature shows that the disease is advancing, 
or that untoward complications are setting in. 

A fever temperature of 104° to 105° Fahr., in any disease, indicates 
that its progress is not checked, and complications may still occur. " 

Certain 'diseases have been found to have typical ranges or daily 
fluctuations of temperature throughout their course ; so that their 
11 differential diagnosis" may be thus assisted materially. This has 
now been determined, especially, in malarious fever, typhus, typhoid, 
smallpox, scarlatina, measles, rheumatism, pyaemia, pneumonia, and 
acute tuberculosis. Dr. Da Costa has observed that in some cases at 
least, cancer is attended by a lowering of temperature. 

In continued fevers the temperature is generally less high in the 
morning than in the evening. Stability of temperature from morning 
to evening is a good sign ; on the other hand, if a high temperature re- 
mains stable from evening till the morning, it is a sign that the patient 
is getting or will get worse. 

AVhen the temperature begins to fall from the evening to the morn- 
ing, it is a sure sign of improvement ; but a rise of temperature from 
the evening till the morning is a sign of his getting worse. 

1 See Aitken, op. citat., vol. i. p. 44. 



80 SEMEIOLOGY. 

Convalescence from disease does not begin until the normal tem- 
perature of the body returns, and maintains itself unchanged through 
all periods of the day and night. 



INSPECTION OF THE BODY AFTER DEATH. 



S y 



In conducting post-mortem examinations, with a view either to 
pathological study or medico-legal investigation, order and method 
are of great importance. 

The three great cavities — the head, the chest, and the abdomen — 
should always be examined, whether suspicion of disease in them exist 
or not. First, however (the autopsy being made from twelve to thirty- 
six hours after death), we should note the external appearance of 
the body ; its size, weight, conformation, color of the skin, etc. (In 
cases of suspected violence even abrasions should be minutely de- 
scribed.) 

To examine the Head, an incision should be made through the scalp, 
across the top of the head, from ear to ear — the two flaps thus formed 
should be reflected, the one over the forehead, the other over the 
occiput. The nature of the attachment of the occipito-frontalis muscle 
to the bone beneath is such as to allow, very easily, the loosening of 
the scalp. The cranium (calvaria) is now to be removed by means 
of a small saw. 

For the purpose of holding the head firmly during the use of the 
saw, Dr. Demme has furnished, as a substitute for the craniotome 
of Mr. Lund, of London, a cranium-holder, which enables the opera- 
tor to make a section of the skull in any direction. It consists simply 
of a bar of iron curved like the letter U, at each extremity of which 
two drill screws are placed, which, when forced down upon the bone, 
hold the bar firmly in situ, and enable the examiner to control the 
head. The legs of the instrument, for use, are placed upon the lateral 
portions of the skull, over the squamous portions of the temporal 
bones. 

The section of the cranium with the saw should be made through 
its outer table, completely around the head — from before, backward, 
from below the frontal protuberances to the squamous portion of the 
temporal bone, and from behind, forward, from the occipital protu- 
berance to the squamous portion of the temporal bone, meeting the 
line just described. The shape of the piece thus cut out enables it 
to be maintained in its proper position when the parts are readjusted. 
It is removed by the aid of an elevator or chisel, and hammer, fractur- 
ing the inner table of the skull by strokes so applied as not to pierce 
the brain. 

The dura mater is next to be cut through, on each side of the 
superior longitudinal sinus ; after which, dividing the falx cerebri, the 
brain may be raised carefully with the hand placed under its anterior 
portion. The internal carotid artery, and cranial nerves, etc., are 
now to be severed by the knife, and, finally, the vertebral arteries and 
spinal cord. The brain itself may then be taken out, and inspected, 
by slicing it, from the upper part downward, in successive horizontal 
layers. 

To examine the spinal column, an incision should be made from 



TEMPERATURE IN DISEASE. 81 

the occipital protuberance to the extremity of the os coccyds. The 
deep muscles of the back should then be loosened from their attach- 
ments, so as to expose the laminae and spinous processes of all the 
vertebras. With the chisel and mallet, or saw, we must cut through 
the arches of the vertebrae on each side, close to their articular pro- 
cesses. After thus opening the spinal canal, the cord is to be exposed 
by dividing the dura mater through its whole length. 

To examine the Neck, an incision should be made through the skin, 
extending from above the hyoid bone to the upper part of the ster- 
num. Avoiding penetration of the large veins of the neck, the parts 
to be examined may be carefully dissected, and, if desirable, removed 
from the body. The thyroid gland, larynx and its appendages, tongue, 
pharynx, oesophagus, bloodvessels, and nerves of the neck, may be 
thus viewed. 

To examine the Chest, two incisions are desirable : the one from 
the root of the neck, in front, to the extremity of the ensiform carti- 
lage ; the other at right angles to this, across the middle of the thorax. 
The cartilages of the ribs are to be cut through at the line of junction 
with the ribs. The ensiform cartilage, being drawn outward, is to be 
detached from the soft parts, the knife being held close to the sternum. 
The sterno-clavicular articulation may now be opened, and the ster- 
num with the costal cartilages raised from its position — a cautious use 
of the knife being made to remove the adherent soft parts. 

The thoracic viscera are now exposed, and may be drawn out with 
care, and inspected in detail. 

To examine the Abdomen, make a crucial incision : the one branch 
extending from the sternum to the pubes, passing to the left of the 
umbilicus ; the other, transversely across the middle of the abdomen. 
Care must be taken, in making these incisions, not to injure the sub- 
jacent viscera. 

Before removing the stomach or any portion of the intestines, liga- 
tures should be placed above and below the part that is to be sepa- 
rated. 

When — as is always desirable if possible — both of the large cavities 
of the trunk are to be opened, a single incision, extending from the 
top of the sternum to the symphysis pubis, may be made. 

In every case incisions through the skin should be made, as far as 
practicable, only in those parts which are usually covered by the 
clothes of the deceased. It is generally advisable, when the abdomen 
or thorax has been opened, to fill the cavities with bran or sawdust. 
After the examination has been completed, the edges of the divided 
integument should be brought together, and retained in apposition by 
the common suture. 

MEDICO-LEGAL EXAMINATIONS. X v 

In cases of suspected poisoning, the following practical directions 
are given by Professor Reese, of the University of Pennsylvania ; to 
be observed by those who have charge of the post-mortem examina- 
tions : — 

1. Ascertain whether the individual has labored under any previous 
illness ; and how long a time had elapsed between the first suspicious 



82 SEMEIOLOGY. 

symptoms and his death ; also, the time that had elapsed after death 
before the inspection is made. 

2. Note all the circumstances leading to a suspicion of murder or 
suicide — such as the position and general appearance of the body, and 
the presence of bottles or papers containing poison about his person, 
or in the room. 

3. Collect any vomited matters, especially those first ejected, and 
preserve them in a clean glass jar, carefully stoppered and labelled. 
The vessel in. which the vomited matters have been contained should 
be carefully inspected for any solid (mineral) matters which may have 
sunk to the bottom, or adhered to the sides. If no vomited matters 
be procurable, and vomiting has taken place on the dress, bed-clothes, 
furniture, etc., then portions of these must be carefully preserved for 
future examination. 

4. Before removing the stomach, apply two ligatures beyond each 
extremity, dividing between each pair, so as to prevent the loss of 
any of the contents. 

5. If the stomach is opened for inspection, this should be performed 
in a perfectly clean dish, and the contents collected carefully in a 
graduated vessel, so as to properly estimate their quantity. [Note 
here, also, the presence of blood, mucus, bile, or undigested food.] 
These contents should be preserved in a perfectly clean glass jar, 
securely stoppered, covered over with bladder, and sealed. The con- 
tents of the duodenum should be collected and preserved separately. 

6.. Carefully inspect the state of the throat, oesophagus, and ivind- 
pipe for the presence of foreign substances, and for marks of inflam- 
mation and corrosion. 

7. Observe the condition of the large intestines — especially the 
rectum : the presence of hardened feces would indicate that purging 
had not very recently taken place. 

8. Note any morbid changes in the lungs, as congestion, inflamma- 
tion, or effusion ; — in the heart, as contraction, flaccidity, presence of 
a clot, and condition of the contained blood. 

9. Examine the state of the brain and spinal marrow : and, in the 
female, the condition of the uterus, ovaries, and genital organs. 
[Poisons have sometimes been introduced into the vagina.] 

10. Along with the contents of the stomach and duodenum, the 
viscera that are to be reserved for chemical analysis are the stomach 
and duodenum (to be kept separate from the others) ; the liver and 
gall-bladder, spleen, kidney, rectum, and urinary bladder with its con- 
tents. Sometimes, also, a portion of the blood may be required for 
the examination. 

11. As the legal authorities will rigorously insist upon proof of the 
identity of the matters alleged to be poisonous, it is of the greatest 
importance to preserve such matters from all possible contamination 
by incautious contact with a surface or vessel which is not absolutely 
clean. Avoid the use of colored calico or paper for wrapping up the 
specimens. When once the suspected articles are deposited in the 
hands of a medical man, he must preserve them strictly under lock 
and key, and confide them only to a trusty agent for transportation. 
Many cases are on record where the chemical evidence failed, simply 



GENERAL THERAPEUTICS. 83 

from a want of power clearly to establish the identity of the matters 
analyzed. 

Actual testing for poisons in cases of suspected criminality ought 
to be undertaken only by those whose chemical knowledge and skill 
are considerable. (See Taylor's Medical Jurisprudence.) 



SECTION III. x y 

GENERAL THERAPEUTICS. 

Eemedies have been classified, for the study of Materia Medica, 
in a manner (see Wood's Therapeutics and Pharmacology) which is 
perfectly well adapted to the present state of that science. 

I propose the following classification, from the standpoint of the 
practitioner; i. e. according to the indications of treatment, or 
objects proposed. 

Thus regarded, remedies may be studied as — 

Anodyne and calmative \ e.g. opium ; ether ; chloroform ; aconite ; 
hydrocyanic acid. 

Protective : e. g. demulcents ; surgical dressings. 

Balancive : e. g. cold to an over-vascular part ; pediluvia ; blood- 
letting. 

Economic: rest; astringents; retarders of tissue-metamorphosis. 

Eliminative : e. g. colchicum in gout ; purgatives ; iodide of potas- 
sium, etc. 

Antidotive: e.g. hydr. ox. of iron for arsenical poisoning; anta- 
cids ; cinchonization in intermittent. 

Alterative: e. g. nitrate of silver in scarlatinal sore throat ; arsenic 
in skin diseases; electricity in cancer. 

Repuperative : stimulants; tonics; chalybeates ; oleum mo rrhua? ; 
travelling. 

An elaborate work might, of course, be written upon the topics 
just enumerated. It is appropriate to our purpose, only to state 
them ; dwelling, presently, upon another yet more brief classification, 
of the modes of treatment most frequently called for, in the manage- 
ment especially of acute and subacute affections. 

First, a few words upon balancive measures. These constitute a 
very large part of therapeutics ; one of the most constant elements of 
disease, and of diseases, being, a disturbance of the proportion of 
circulation, nutrition, innovation and action in different parts. 

For example : when one "takes cold," what has occurred? Chill- 
ing the surface, as by damp air, has checked perspiration, contracted 
the superficial bloodvessels, causing congestion of interior organs, 
and partial contamination of the blood, from retained excretory matter. 
What, then, is the "indication" or pointing of nature? 

Clearly, it is, to restore the lost balance ; by tvarmth to bring on 
perspiration (unless fever occurring demand another method), purga- 



84 GENERAL THERAPEUTICS. 

tives and diuretics, with plenty of water, to relieve the blood of its 
morbid excess of excreta. 

Again, in flatulent colic, unequal distension and spasmodic con- 
traction of a bowel occur, from gaseous accumulation or the pre- 
sence of irritating ingesta. Aromatics, such as ginger; stimulants, 
as hot water or brandy; or anodynes, as camphor or opium, by a dif- 
fusive action on the whole surface of the affected intestine, and upon 
its innervation, when they are absorbed and reach the ganglia, will 
renew a proportionate contraction (peristaltic) of the muscular coat, 
and remove the pain. Yery often gentle friction, pressure or kneading 
the abdomen, or external warmth all over it, will have a similar 
balancive effect. 

Laxatives for deficient movement of the bowels, astringents for 
excess of the same, cold to a too hot head, and mustard and hot water 
to cold feet, are all balancive means. So is the familiar, and always 
safe use of a mustard-plaster to the skin, over any part of the body 
which suffers pain. Pain denotes a morbid innervation, from some 
cause. Apply something which, like mustard, causes a strong impres- 
sion in a different place, not too remote, and the " error loci" of 
nerve-tension (or debilitation, 1 as the case may be), is done away 
with — the balance is restored. 

Notice may be here taken, briefly, of a new " method" in therapeu- 
tics, extending the balancive principle systematically, — called the 
" neuropathy" (ganglio-therapy) of Dr. John Chapman. 

The origin of this is really to be credited to the vivisections of 
Bernard and Brown-Sequard, 2 and conclusions based upon them, espe- 
cially by the latter. The experiment of most importance in this con- 
nection has been the section of the sympathetic nerve in the neck of 
a rabbit ; which was found to be followed by dilatation of the blood- 
vessels of its ear. It was concluded from this and other facts simi- 
larly obtained (all traumatic or pathological, as, indeed, are all facts 
of vivisection), that to increase the amount of blood and sensibility 
in any part of the body, you must 'paralyze, partially or temporarily, 
its sympathetic ganglion. To diminish its vascularity and sensibility, — 
you should excite its vaso-motor nerve-centre. 

Dr. John Chapman systematizes the application of these principles, 
by the application of elastic bags, containing ice, or hot water, along 
the spine; so as to act upon the ganglia located thereupon, and, 
through them, to affect the viscera, both palliatively and curatively, 
in disease. 

If the physiological theory of Brown-Sequard, above mentioned, be 
true, the therapeutical process of Chapman, deduced from it, may be 
justified. I deny the truth of the one, and, a priori, have no belief 
in the validity of the other. Clinical experience, however, must 
decide the claims of the practice. 

It must be remembered, that a practice may prove beneficial, 
whether the theory which suggested it be correct or not. Hot and 
cold applications to the spine must make (especially when alternated, 

1 Radcliffe " On Epilepsy, Pain and Paralysis ;" Inman, op. citat. 

2 See his Lectures on the Nervous System, p. 205, &c. See, also, a discussion 
of the experiment mentioned, in the author's Essay on the Arterial Circulation. 



ANTIPHLOGISTIC TREATMENT. 85 

as Brown-Sequard proposed for bed-sores) a strong impression on the 
whole system ; this may prove a rapidly alterative impression in 
certain cases of disease. Should this prove so, the use of such means 
should be adopted, just as, and .so far as, experience shows it to be 
useful. No such utility of applications whose explanation may be 
reached in many different ways, can make the theory above cited 
seem, to the present writer, other than erroneous. 

The modes of treatment most frequently called for, in ordinary 
medical practice, may be designated as — 

The antiphlogistic ; The supporting ; 

The febrifuge ; The antidotive ; 

The alterative treatment. 

Under the first head, the antiphlogistic (*. e. the treatment of in- 
flammation), we place — 

Rest ; — position ; Tartar emetic ; Digitalis ; 

Cold applications ; Nitrate of potassa ; Ergot ; 

Venesection; . Ipecacuanha; Mercury; 

Local depletion ; Veratrum viride ; Opium ; 

Purgation; Diet; Aconite; Counter-irritation. 

The necessity of rest during active inflammation of any organ is a 
rule without exception. 

A choice of position is often dictated by the sensations of the 
patient. When one of the extremities is inflamed its elevation is 
advised in order to allow the blood to return from the overloaded 
vessels. 

Cold applications are very important in the treatment not only of 
inflammation, but of active hypercemia or congestion (e. g. " determi- 
nation of blood" to the head). The two precautions most necessary 
in their use are, that the cold be not excessive, and that it be not ill 
timed, so as to arrest desirable perspiration. 

Blood-letting, by venesection, leeching, and cupping, is one of the 
oldest, and has been one of the most universal of remedies for inflam- 
mation. Although ''atuo-jKoGot,'' or "blood-fearers," have occasionally 
appeared in all ages and nations, yet the aggregate testimony of the 
profession, from Hippocrates down to the present time, has been in 
favor of the use of the lancet and of local blood-letting in the treat- 
ment of violent inflammation and congestions. 

Now, however, it must be admitted that blood-letting has more op- 
ponents and fewer defenders than at any previous period in medical 
history. Why is this ? By reason of — 

1. Reaction from previously existing abuse of the remedy. 

2. A change in the average human constitution, occurring under 
the artificial habits of civilized life. 

3. False construction and misapplication of recent science. 

4. Leadership and fashion. 

I must briefly remark, that the reaction alluded to has proceeded 
too far, going from one extreme to another. 

The change occurring especially in large cities, in the average human 
constitution, affords good reason for limiting the use of the lancet to 
a smaller number of cases than was once thought necessary ; and for 
8 



86 GENERAL THERAPEUTICS. 

rising especial caution as to the amount of blood abstracted ; but not 
for abandoning the remedy altogether. 

The improved condition of the sciences of semeiology and pathology 
gives us the power to discriminate more narrowly in our use of blood- 
letting, as well as of other remedies. But, we should not, for this, 
throw aside as useless all the experience of our predecessors; as if 
every new fact was necessarily the heir of some dead old one. All 
facts, old and new, should be retained. 

In the physiological and pathological science which bears upon the 
question, I hold that false construction and misapplication of observed 
facts have been operative. An important threefold error has been 
committed; viz. — 

1. In physiology, the denial or depreciation of the active part taken 
by fche arteries in the circulation ; and of the great fact, without 
recognition of which no theory of inflammation can stand, that the 
arteries are subject to reflex excitement, — the most normal form of 
which constitutes active hyperemia, the most abnormal and excep- 
tional, tonic constriction of the vessels. 

2. The error of Prof. J. H. Bennett, of giving attention, in regard 
to the pathology of the inflammatory process, to the exudation alone. 

3. That of Prof. Yirchow, in considering that no important differ- 
ence in kind exists between morbid lesions of nutrition in vascular 
and in non-vascular tissues ; and that stimidation, irritation, and 
inflammation are, essentially and practically, as well as causatively, 
only degrees of the same vital impression. 

The theory of inflammation which has been already laid down, 1 as 
entirely consistent with the observations (whatever may have been the 
reasonings) of the most accurate pathologists (e.g. Rokitansky, Paget, 
Wharton Jones), inculcates, that the determination of blood toward 
an inflamed part conspires with the central stasis in causing the exu- 
dation ; and that a constant proportion exists between the degree of 
this active turgescence and the amount of the exudation, and the 
character of the changes which it subsequently undergoes. 

Now, of the cardinal elements of the inflammatory process, the 
local arrest of nutrition and ca,pillary stasis cannot be directly affected 
by treatment. Nor, when the exudation has occurred, can any but 
palliative or expectant measures be applied to the management of its 
changes. But, the active concentric determination of blood — the ar- 
terial excitement — cannot this be essentially modified by treatment ? 
Yes. 

By abstraction of blood, we lessen (for a time at least) — 

1. The fulness of the vessels; 

2. The number of red corpuscles ; 

3. The force of the heart's impulse ; 

4. The force of the arterial impulse ; 

5. The excitement of nerve-centres. 

And by each and all of these influences, we diminish the vascular 
excitement connected with an inflammation ; and thus (I repeat) 
lessen the amount of the resultant exudation, and (Paget) render its 

1 See General Pathology, Section III. 



BLOOD-LETTING. 87 

" biography" more normal, its changes less degenerative and destruc- 
tive. ' 

If this be true, it is altogether an erroneous assumption, of Professor 
Bennett, and others, that inflammation is a " self-limited process which 
cannot be cut short nor interfered with to advantage." If there be 
anything positive in medical experience, I believe the contrary of this 
to have been established. 

Thus much, perhaps, must be allowed to the influence of recent 
ratiocinations and experimentations in medical practice without the 
lancet; that local blood-letting may be admitted, in almost every case, 
to have all the advantages which can be claimed for venesection, ex- 
cept convenience; and that, in doubtful cases, the smaller quantity 
abstracted ought always to be an argument in favor of local rather 
than general depletion. This admission may be made without sur- 
rendering, in the least degree, the principle of therapeutics upon 
which blood-letting is scientifically justified, and according to which, 
if we are to interfere at all with disease, it is often one of the mildest, 
most beneficent, and least hazardous of remedies. Dr. J. H. Bennett 
admits that relief of pain, dyspnoea, &c, sometimes follows bleeding ; 
and this concession carries a good deal with it 

How, then, it is proper to ask, do we define or classify the remedial 
action of blood-letting? 

It is balancive. What do we mean by reducing treatment? The 
answer to this question is important. 

/ do not know of a single case of any kind of disease, in which the 
indication or object of medical treatment is to reduce the strength, or 
lower the vital 'power of the patient's system. 

What we aim to reduce is, disproportionate vascular excitement, 

1 It may be hoped that the time has gone by when any question in thera- 
peutics can be decided by leadership. But the "blood-letting controversy" 
has shown, that the medical mind is not yet absolutely free from its influence. 
As to authorities, old and new, it may interest the student to remember, that, 
of ancient opponents to the lancet, Chrysippus and Erasistratus were the most 
noted; of the modern European schools, Van Helmont, Diet), and Skoda, in 
Germany; Grisolle, in France ; Bennett and Todd, in Great Britain. Exem- 
plification of Sangrado's practice, on the contrary, has been especially accredited 
to Cullen in England, Rasori in Italy, Chomel and Bouillaud in France, and 
Rush (the father of American medicine) in this country. We should place in 
the class of moderate bleeders, of antiquity, Hippocrates, Asclepiades, Celsus, 
Galen, Avicenna, and " hi TrckXot ;" of earlier English and French teachers, 
Sydenham, Huxham, Gregory, Laennec, etc. ; of the present date, the recently 
deceased Professor Alison, with Watson, Christison, Copland, Lawrence, 
Chambers, Parkes, C. West, W. T. Gairdner, Symonds, F. Winslow, Aitken, 
and others in Great Britain ; Wunderlich in Germany ; and, in this country, 
as a representative of American medical conservatism, G. B. Wood. As 
statistics have been especially appealed to by the opponents of blood-letting, it 
may be proper to quote here the conclusion of an able analysis of all the evi- 
dence of this kind made public {Brit, and For. Medico- Chirurg. Rev., July, 
1858). It is as follows :— 

"While the non-bleeding plan has a demonstrable advantage over that of 
indiscriminate and repeated bleedings, we maintain that the discriminating 
practice of moderate and early bleeding, general or local, in cases of more or 
less sthenic inflammation, and of refraining from it altogether in asthenic 
cases, whether as regards the character of the disease or the constitution of the 
patient, is pressed upon us both by experience and science."" 



88 GENERAL THERAPEUTICS. 

or congestion ; to restore the balance of the circulation. It is a 
mere imagination that abstraction of a small quantity of blood must 
always lower the patient's strength. Under some circumstances, it 
actually increases it. At the same time, there are many persons who 
will never bear bleeding, from an actual deficiency or defective quality 
of blood. 

Taking these propositions as established, we may draw blood, locally 
or generally, for 

1. High, sthenic inflammation : 

2. Active congestion, threatening inflammation or hemorrhage ; 

3. General plethora, ditto ; 

4. Sthenic spasm; 

5. Sudden passive congestion (not toxsemic) in robust persons. 
It must be remembered that, at the present time, no one thinks of 

bleeding for fever, as such. 

Repealed venesections are seldom now resorted to ; the time for 
the lancet, if at all, is always in the early stage of a phlegmasia. 

It would be instructive, if compatible with our plan, to allude 
farther, especially, to the use of blood-letting in certain cases of 
pregnancy, and of convulsions ; and to the caution necessary in its 
application to the treatment of senile apoplexy. Old persons rarely 
bear bleeding well. 

We might also, if space allowed, illustrate the principles above laid 
down, by examples ; as, of 1, erysipelas ; 2, pneumonia ; and 3, menin- 
gitis. Why is bleeding seldom called for in the first, more frequently 
in the second, and quite often in the last ? 

Our answer is, — that it depends chiefly upon the anatomical rela- 
tions of the tissue involved. The skin is unlimited in its opportunity 
of hyperaemic expansion, and escape of exudation. The lungs are 
partially confined and limited, by the pleura and walls of the chest. 
The brain and its membranes are shut entirely within the closed skull. 
Therefore the influence of vascular pressure (which is most affected 
by blood-letting) is most marked and most important in congestion or 
inflammation of the brain, next so in that of the lungs, and least of 
all in that of the skin, as in erysipelas. 

In uraemia, when the patient will bear it, venesection may do good, 
by taking out the excreta with a portion of the blood, and favoring 
secretion by general relaxation. 

As to the quantity of blood taken by venesection, twelve fluidounces 
may be stated as a full, though not large, bleeding for an 1 adult man ; 
ten fluidounces for a woman. For infants and children, one ounce 
under one year, two ounces under three years, three ounces under five 
years, four ounces under ten years, would be a full average. Bleeding 
from the jugular vein is sometimes preferred in young children. The 
practitioner should judge for himself of the effect upon the pulse, &c. 
It is remarkable how small an amount will sometimes do a great deal 
of good. 

Cut cups and leeches act alike as to the abstraction of blood ; but 
the former have a more revulsive or counter-irritant effect. 

Leeching, being somewhat less violent, is more applicable than cup- 
ping to parts which are very tender ; as, the side in acute pleurisy ; 
the abdomen in peritonitis; a much inflamed joint, &c. 



PURGATION — DIET. 89 

Leeches are usually, for the same reason, applied as near as possi- 
ble to the part inflamed ; cups, sometimes, at a short distance from it. 

In bronchitis, it is ordinarily best to apply leeches or cups to the 
upper sternal region. 

In pneumonia, they may be preferably applied betiveen the shoul- 
ders, as a general rule, thus leaving room for counter-irritation in 
front. 

In pleurisy, it is desirable to use leeches immediately over the in- 
flamed part. 

Purgation, especially by saline cathartics, is a frequently useful 
part of antiphlogistic treatment. 

Cathartics are to be avoided in enteritis and peritonitis ; for obvi- 
ous reasons. 

Diet, in cases of sthenic inflammation, should be non-stimulant ; 
but it may be sufficiently nourishing (vegetable, farinaceous) at the 
same time. Starving patients is not now thought of unless they are 
fearfully plethoric. In the later stages of inflammatory disorders — in 
fact, as soon as the exudation has all been thrown out, generous diet 
is usually required. Some patients will never bear a purely vegetable 
diet under any circumstances ; and some cases, even of inflammation, 
require stimulation from the first. 

The idea of the association, always, of low diet with inflammation, 
has been too absolute in common practice. When, in acute disease, 
the stomach refuses to digest food, it is vain to force it upon it. But, 
it will often digest liquid food when it cannot solids. And, as some 
degree of debility is constant in disease, alimentation being necessary, 
concentrated liquid food, e. g., beef-tea, will frequently be appropriate, 
when no solid substance at all can be taken. 

I believe the principal requisites of diet in illness to be, liquidity 
and facility of digestion and assimilation. In an irritable, febrile state 
of the system, the presence of a solid body, as meat, or bread, in the 
stomach, when no digestive fluid is secreted to act upon it, has the 
effect of a foreign substance, — namely, irritation ; sympathy with 
which may disturb or increase existing disturbance of the whole eco- 
nomy. 

Practically, I have seen, in a person not robust, suffering from 
catarrhal fever, the drinking of a wineglassful of beef-tea followed 
by a copious perspiration and cooling of the skin. Still, a young and 
previously healthy patient will often do best in the early stage of in- 
flammatory disease upon small or moderate amounts of what are called 
articles of sick diet ; as, oatmeal gruel, toast-water, panada, arrow-root, 
&c. In disorders not affecting the bowels, fruits, especially white 
grapes and oranges, need seldom be withheld. They are often refrige- 
rant and useful ; and such is very frequently the effect of lemonade ; 
which acts as a good diuretic and diaphoretic. 

The most powerful of antiphlogistic (arterial sedative) medicines 
is tartar emetic. 

The "contro-stimulant" plan, of giving very large doses of this drug 
in pneumonia, pleurisy, etc., has been abandoned as excessive and in- 
jurious. We need never give more than £ of a grain of tartar emetic 
at a dose to an adult — oftener \, T ^, etc. Children require especial 
caution in its use, on account of the sensitiveness of their alimentarv 

8* ' 



90 GENERAL THERAPEUTICS. 

canal. I have known severe vomiting to be induced in an infant by 
g 1 ^ of a grain. No other medicine as yet discovered, however, is so 
useful in violent inflammations of the pleura, lungs, bronchial tubes, 
etc. 

Tartar emetic (of course) must never be given in gastritis or 
enteritis. 

Nitrate of potassa is a very valuable adjunct to, or in some cases 
substitute for, the antimonial tartrate. It is often given in too small 
doses ; ten grains may be a minimum for an adult, if the stomach is in 
an ordinary state. 

Ipecacuanha is especially valuable in bronchial, tracheal, and 
laryngeal inflammations, and in dysentery. 

Veratrum viride is, lately, assuming an important place as a 
cardiac and arterial sedative, and promoter of the secretions. It is a 
very certain reducer of the pulse, but requires caution in its use. 

Aconite is, likewise, a favorite medicine with some practitioners, 
in the management of pleurisy, pneumonia, etc. 

The power digitalis has been supposed to possess, to reduce the 
rate of action of the heart, 1 has induced the expectation that it would 
prove a reliable antiphlogistic remedy ; but this expectation has been 
disappointed. It is, however, occasionally useful in bronchitis, etc. 

Ergot has been employed with the same view, rather as a direct 
sedative to the smaller arteries. It is quite possible that its powers 
have not as yet been sufficiently tested. 

The place of mercury had appeared, until within a few years, to be 
settled. Twenty-five years ago, nothing was more common than 
intentional mercurial salivation in the treatment of almost all violent 
acute and even chronic diseases. In the management of inflammation, 
in addition to its powerful alterative influence, tending to displace, by 
its own impression, morbid actions and conditions, it was believed to 
exert a peculiar control over the blood, lessening the tendency to the 
effusion of coagulable lymph. 

In recent times, the " salivating" practice has been almost entirely 
abandoned, as disproportionately violent, as well as uncertain. A 
reaction, somewhat similar to that occurring in the case of blood- 
letting, has even shaken the confidence of many practitioners in the 
value of mercury as an antiphlogistic. 

My own opinion, very decidedly, is this. That experience fully 
warrants the inference that mercury is a general stimulant to all those 
functions of organic life which are performed under innervation from 
the ganglia of the (so-called) sympathetic system. It is probable that 
its action is directly upon these ganglia. Thus, mercury tends to 
diffuse and equalize secretion, 2 and the circulation of the blood, aiding, 
in this way, to break up local congestions and inflammations. 

I believe that calomel and blue mass, etc., have been shown to be 
useful in the treatment of several of the acute phlegmasia^. I do not 
think that a due regard for the principles of evidence in therapeutical 

1 Facts have been urged of late which lend force to the opinion that digitalis 
is, primarily, rather a tonic than a sedative to the heart. 

2 Very few points in practice are, for instance, so well sustained by experi- 
ence, as the familiar use of small doses of blue pill, in the treatment of indi- 
gestion with torpidity of the liver and bowels, etc. 



OPIUM. 91 

science can allow us to put aside the proof of this, deduced from actual 
experience. 

Moderate doses, at the same time, are capable of doing all that we 
can safely/ aim to effect with the use of mercurials. I do not know of 
any variety or form of disease in which I should, at the present mo- 
ment, feel justified in intentionally causing full salivation as a means 
of medical treatment. 

Mercury is especially contra-indicated in the presence of the tuber- 
cular diathesis. 

Opium, always the most reliable and potent of anodyne medicines, 
has, in latter times, assumed a more important position as a remedy 
in the treatment of inflammatory diseases. 

Experience has warranted this, while certain theoretical considera- 
tions have also been urged in regard to it. 

1. The influence of the nervous centres upon inflammation (as upon 
normal nutrition, circulation, etc.), and the intimate interconnection 
of the two portions, organic and sensori-motor, of the nervous 
apparatus, are now more fully recognized than formerly. 

2. Opium (morphia) is believed by some to act directly, not only 
upon the cerebro-spinal, but also upon the ganglionic nevve-cells as a 
peculiar stimulant, thus affecting the circulation, nutrition, etc., other- 
wise than by mere sympathy. 

Yet, in estimating the adaptation of preparations of morphia or 
opium to the treatment of inflammations of important organs, in differ- 
ent stages, we must remember, that 

Opium is an arterial stimulant, and is, therefore (as a general rule), 
inappropriate in the early stage of an active sthenic phlegmasia. 

Opium first excites, and then oppresses the brain ; in a word, pro- 
motes determination of blood to the head, and is, therefore, contra- 
indicated by an already existing tendency to cerebral congestion. 

Opium also constipates the bowels — a fact of less importance than 
either of the two preceding, as the constipating tendency can be 
counteracted, if desirable, by other medicines ; while, in certain cases, 
it aids in the treatment (as in dysentery) . 

In peritonitis, where the extent and visceral connections of the tissue 
affected induce more rapid prostration, and more serious nervous 
irritation than in any other phlegmasia, opium has become the main 
dependence with very many practitioners, even from the beginning 
of the attack. The same reasoning will. apply, to a somewhat less 
extent, to its use in severe cases of -pleurisy and pericarditis. 

Counter-irritation is a measure of treatment often of great service, 
especially in the later stages of inflammation (after local or general 
depletion, etc.) , or in cases unattended with much vascular excitement. 
In the very incipiency, or rather incubation, of an inflammatory 
attack, i. e., in the stage of mere irritation or congestion, counter- 
irritation (e. g. by a sinapism) may prevent the further progress of 
the inflammatory process. But, if the stasis and concentric hyperemia 
be already developed, all powerful counter-irritants should be avoided 
(lest they prove co-irritants) until the vascular disturbance has sub- 
sided. 

Counter-irritation is, usually, the most important part of the treat- 
ment of hypersemgesthesia, or "chronic inflammation." 



92 GENERAL THERAPEUTICS. 

To recapitulate the order of time, in which long recognized 
experience has prescribed the use of the different means now included 
under the term " antiphlogistic" treatment : — 

Supposing all' of the main remedies of this class to be called for in 
a given case, we would resort first to venesection ; or, if this be unde- 
sirable, to cupping or leeching ; next, to saline purgation ; then, to 
tartar emetic, nitrate of potassa, ipecacuanha, veratrum viride or 
aconite; mercury at the same time, or immediately following these 
sedatives ; opium sometimes with it or them — oftener, a little later ; 
counter-irritation by blisters, 2 etc., last. The subsequent debility, espe- 
cially in cases of suppurative inflammation, may call for tonics or 
even stimulants, with generous diet, etc. ; while certain cases will even 
require such treatment from the first. 

The treatment of subacute or chronic inflammation, in external or 
accessible parts, by astringents or stimulants (e. g., nitrate of silver), 
does not require, in this place, extended discussion ; as it usually 
comes under the domain of Surgery. One example, however, of its 
medical utility, may be named — viz., the administration of nitrate of 
silver (gr. ± — f ter die) in chronic gastritis. The change which it 
undergoes in the intestines, when given by the mouth, explains the 
fact that the same medicine fails to exhibit a similar beneficial influ- 
ence in chronic enteritis. In prolonged dysentery, however, enemata 
containing this or some analogous mineral salt, as sulphate of zinc, 
sulphate of copper, or acetate of lead, are often very valuable reme- 
dies. 

We cannot leave the subject of the management of inflammatory 
disease without reminding the student of the important practical dif- 
ference between sthenic and asthenic inflammations. 3 

This difference is constituted — 

1. By the state of system of the patient affected ; 

2. By the nature of the producing cause. 

One whose constitution has been prostrated by previous disease, or 
recent excess, will have, when exposed to the ordinary causes of 
inflammation, an asthenic attack ; i. e. one in which, with all the local 
symptoms of phlogosis, the general organic functions are sympatheti- 
cally affected rather with depression than with excitement. 

Again, certain morbid poisons induce, with toxaemia, local inflam- 
mation ; and blood-disease (dyscrasia), arising from various causes, 
may have local inflammation as a secondary effect. In these cases 
the type of the inflammation is generally asthenic, and the treatment 
must be modified accordingly — depletion being avoided, or used with 
the greatest caution, and full diet and even stimulation being not un- 
frequently called for. 

As examples of inflammations which may be either sthenic or 

1 Of course, this supposition, of the successive use of all of the remedies 
named in this paragraph, does not, in very many cases, need to be realized. 

2 Dr. Inman, of Liverpool, suggests that the so-called counter-irritants really 
act, by absorption, as direct stimulants, to parts enfeebled by disease. It is 
quite possible that, in some cases at least, this may be true. 

3 Granting that all disease is debilitating (Inman), the distinction is still 
valid and important, as to the different degree of depression produced by its 
different forms or types. 



TREATMENT OF FEVER. 93 

asthenic. I may mention erysipelas, dysentery, peritonitis, pneumonia, 
govt 

The first three' of these are at times epidemic ; and then it is that 
the greatest number of asthenic cases is observed. The following 
maxim may be considered as fully established : — 

Whenever any local affection, as clyserdery. peritonitis, catarrh or 
pneumonia, occurs sometimes sporadically (*. e. in altogether sepa- 
rate or independent cases) and sometimes endemically or epidemi- 
cally (*". e. a number of cases at the same place and time, under a 
common local or temporary cause), the latter cases exhibit, as a rule, 
the greatest tendency to depression in their symptoms, the largest 
mortality, the least tolerance of depletory treatment, and the most fre- 
quent need of stimulation or support. 

By febrifuge treatment I mean, that which is proper during the 
existence of the febrile state. It comprises no violent measures of 
any kind. 

Remembering that the essential phenomena of fever are, increased 
heat, especially of the exterior of the body, dryness of its surfaces, 
scantiness of fluid in all the discharges, with actual increase in their 
solids, from accelerated tissue-metamorphosis — our therapeutics must 
be adapted to these conditions. Apart from the necessity of removing 
or antagonizing, if possible, the cause of the febrile disturbance, the 
indications are. to allay the heat and dryness of the surfaces of the 
body, tegumentary and mucous, and. to favor the removal of excreta, 
accumulated in unusual amount in the blood and organs. 

For these purposes, we may use 

Moderate laxatives ; Cold drinks ; 

Saline diaphoretics ; Tepid ablutions. 

Of these measures. I have no doubt of the propriety of the desig- 
nation of water as the heroic remedy, to which the others are merely 
adjuvants. Diaphoretics will scarcely act at all without free imbibi- 
tion of water, and the operation of laxatives is much promoted by it. 
Water alone is diaphoretic, diuretic, and laxative ; but it maybe aided, 
to an important degree, in alleviating the symptoms of fever, by the 
addition to it of citrate of potassa, acetate of ammonia, etc. \y 

I have already laid emphasis upon the statement, that no one now 
thinks of bleeding for fever, as such. In a much more strict sense. 
pathologically speaking, than inflammation, the febrile nisus is self- 
limited, although variable in its duration according to the cause 
inducing it. The object of the physician is not to cut it short ( jugu- 
lar e), but to conduct it safely to a critical termination. In an equally 
important practical manner, this principle applies, not only to the 
management of a brief or ephemeral exacerbation or paroxysm of 
irritative or reactive fever, but also to those of longer duration, under 
toxemic (zymotic) causation: as exanthematous (rubeolar, scarla- 
tinal, variolous) or continued (typhus, typhoid) fevers. An exception 
is believed by many to exist, in the case of autumnal, miasmatic, 
periodical fevers : i. e. intermittent, remittent, and pernicious (con- 

1 Pneumonia is also sometimes endemic or epidemic, in the form of typhoid 
pneumonia. 



94 GENERAL THERAPEUTICS. 

gestive) ; in which, interference, by the antidotal remedy, cinchona or 
its alkaloids, is considered safe at all times, and sometimes necessary 
before the subsidence of fever. But I believe this exception to be 
only partial, since the most careful recorded experience has given rise 
to the conclusion' that quinine is never necessary during the height of 
the exacerbation of either type of miasmatic fever, and that in large 
doses at that period it may do harm. It is, I consider, the best 
practice always, in the treatment of autumnal remittent (bilious) fever, 
to wait, until the febrile stage has passed its climax, and its symptoms 
have begun to decline — the urgency of the case, and all its circum- 
stances, then, guiding the practitioner as to hotu soon, as well as how 
largely, the special remedy, whose interference is called for, must be 
introduced. 

It is a matter of general remark, that patients scarcely ever die 
during the hot stage of any kind of fever. In the most intense form 
of miasmatic poisoning, called pernicious fever, the danger exists in 
the extreme depression of the cold stage ; if fever comes on, the pa- 
tient is comparatively safe for the time. 

The supporting treatment is that adapted to states of prostration 
or debility. 

General weakness of the body (when not a congenital defect) occurs 
under three forms : — 
Exhaustion ; 
Depression ; 
Oppression. 

We are familiar with the first, exhaustion, as the effect of over- 
exertion, loss of sleep, deficiency of food, excessive discharges, etc., 
and as following acute, or constituting a part of chronic disease. 

The second, depression, is to be discriminated from exhaustion, as 
resulting, not from expenditure or waste of the material or forces of 
the body, but from interference with their normal activity by some 
disturbing cause. To use a mechanical illustration, exhaustion is the 
running down of the clock ; depression, the arrest of the impelling 
movement of the weights, by which its wheels are kept in motion. 

Oppression, then, may be compared to the obstruction of the ma- 
chinery by some foreign body, or by some mechanical disarrangement 
among the wheels, which clogs their action until it is removed or cor- 
rected. 

Exhaustion and depression have their chief seat in the nerve-central 
sources of dynamic force ; oppression, in the circulation of the blood, 
or in s-ome subordinate organs or functions. 

This distinction, however recondite in theory it may seem to be, is 
of high practical importance. This will be seen on consideration of 
the remedies used and required in the different forms of debility. 

Supporting measures may be classified as — 

1. Stimulant; 

2. Analeptic (recuperative, restorative). 

Under the first head we rank the preparations of ammonia and 
alcohol, etc., as usually employed. 

1 See Medical Statistics of United States Army, 1839-54. 



SUPPORTING TREATMENT. 95 

Under the second are included generous diet, tonics, chalybeates, 
cod-liver oil, change of air, etc. 

Now the first of these (stimulants) are adapted especially to acute 
prostration or depression ; the second class (analeptics), to chronic 
'prostration or exhaustion. Oppression or counterfeit debility, gen- 
erally requires neither, being benefited by very different treatment. 
A mingling or blending of these states is of course possible ; and then 
a union of measures is right, to meet the conjoined indications. 

Oppression (simulating depression) is every day illustrated by the 
condition of a patient in the early stage of any of even the mildest 
acute disorders ; as, catarrh or bronchitis, indigestion, tonsillitis, 
measles, etc. In all of these cases, especially where fever is develop- 
ing, the patient is very weak ; not only as to his muscular apparatus, 
but in the performance of all the animal and organic functions. But 
stimtdation, for such a condition, in persons of ordinary constitutional 
vigor and soundness, would be generally inappropriate, often injurious, 
sometimes dangerous. 

A more serious degree of oppression occurs in some cases of visceral 
congestion, particularly of the lungs or brain ; and in violent spasmo- 
dic affections of the alimentary canal, with constipation of the bowels. 
Urcemia, from inaction of the kidneys, presents another case of 
oppression, in which even a fatal result may occur. 

Counterfeit debility or oppression, then, to recapitulate, may occur 
in — 

The first stage of all acute diseases ; 
The febrile state ; 
Indigestion or dyspepsia ; 
Congestion of the brain, lungs, etc. ; 
Obstruction of the bowels ; 
Uraemia. 

The first of these instances is to be treated usually by measures 
which promote reaction in the mildest manner. More doubt exists, 
however, if the cold stage itself be intense or profound — as in perni- 
cious intermittent — constituting a depression, under toxaemic influ- 
ence. Of this, a word or two presently. 

The febrile oppression is to be managed simply by those palliative 
measures mentioned already under the head of febrifuge treatment. 

That of indigestion is usually temporary or occasional only; and 
gives way under the use of antacids, carminatives, blue pill, etc. 

Violent congestion of the brain or lungs, occurring in a person of 
previously good constitutional strength (although it may produce the 
most absolute debility, which, especially in the case of pulmonary 
congestion, masks the cause of the disorder), calls, if the diagnosis be 
clear, for counter-irritation and the local or general abstraction of 
blood. In doubtful cases a tentative plan may be pursued : abstract- 
ing but a minimum quantity at first, being encouraged to repeat and 
enlarge the depletion only if the result be favorable. 

Constipation, producing oppressive debility, is of course to be met 
by agents calculated to unload the bowels ; anti-spasmodics, anodynes, 
etc., being also indicated, if colic exist, and be not relieved by laxa- 
tives alone. In absolute (mechanical) obstruction of the bowels, 
causing or endangering enteritis or strangulation, the treatment now 



96 GENERAL THERAPEUTICS. 

generally adopted is, to depend upon opium and rest, avoiding purga- 
tives. 

Urcemia demands all the means within our power to restore the 
action of the kidneys; and to aid them in their eliminating duty by 
favoring the cutaneous transpiration and secretion. 

I have already said that mixed cases of oppression and depression 
occur, in which the indications of treatment are, to a certain extent, 
obscure and doubtful. Such are, the cold stage of pernicious (con- 
gestive) intermittent, the incipiency of the algid or collapsed state of 
epidemic cholera, etc. 

It is clear that reaction is here to be brought about, if possible ; 
and that external stimulation, by powerful rubefacients, frictions, etc., 
is altogether appropriate ; but, however authoritatively rules may have 
been laid down, it is not so certain, in every case, whether alcoholic 
stimulation or venesection would afford the better result, or whether 
some cases might not be benefited by both combined. The incompa- 
tibility supposed to exist between blood-letting and stimulation is in 
fact not intrinsic, but circumstantial. Holding distinctly in our 
minds the principle that the object of blood-letting is to balance the 
quantity, consistency, and distribution of the blood, and not to reduce 
the strength of the patient, it is far from impossible that the balancive 
action especially of local blood-letting may be called for in a case in 
which the forces require to be sustained at the same time by "sup- 
porting treatment." 

Personal experience, however, is indispensable to the application 
of these, or any analogous principles, to cases, in regard to the 
management of which the profession has been, but we may hope will 
not always be, divided. The present tendency of medical practice is 
quite too much in the direction of over-stimulation. 

Depression is exemplified in the state produced by — 

Severe injuries ; e. g. railroad accidents ; extensive burns, etc. 

Mental shocks ; e. g. terror or great grief. 

Withdrawal of accustomed stimulation; e. g. delirium cum 

tremore. l 
Intense toxoemia ; e. g. cholera collapse, etc. (see above). 
Gouty spasm, of the heart or stomach, etc. 

Stimulation by alcohol, ammonia, ether, opium, camphor, turpen- 
tine, capsicum, etc. is needed, with greater or less urgency, and in 
larger or smaller doses, in all of these conditions ; always bearing in 
mind the probability of reaction, and avoiding, as far as possible, the 
exaggeration of this reaction into fever. 

The prostration of typhus fever, in a majority of cases [not in all), 
and that of typhoid fever, in a minority of cases, requires, especially 
after the height of the fever has passed, alcoholic stimulation, as well 
as support by concentrated liquid nutriment (beef-tea, milk) at short 
intervals. 

The instances of these fevers afford us a sort of intermediate grada- 
tion between what I have called acute and chronic debility. 

In regard to the latter (the debility of convalescence, chronic dis- 

1 It ia not intended, of course, to indicate that all cases of delirium tremens 
are referable to this cause. 



ANALEPTICS. 97 

ease, etc.), certain principles are agreed upon by all physicians, on 
the ground of experience, confirmed by the deductions of physiological 
science. We shall first briefly consider some of these, and then one 
or two debatable points akin to those already alluded to. 

The two most important and familiar results of clinical experience 
in the treatment of debility, are, the superiority of the pure vegetable 
bitters in stomachic and digestive weakness, and of iron in anaemia 
(spanaemia). The influence of quinia and cinchonia in nervous 
debility is almost as assured. The confidence of many physicians is 
strong in the utility of the mineral tonics (zinc, copper, arsenic, and 
silver salts) 1 in debility with nervous symptoms; e.g. chorea, hys- 
teria, etc. I believe this confidence to be deserved, to a considerable 
extent ; but, some of the diseases in which these medicines are given 
(e. g. epilepsy) will, in many instances, baffle all treatment. The use 
of strychnia in certain cases of paralysis is also well established ; 
although requiring much care and discrimination. 

Cod-liver oil holds, at the present time, a very high place in the 
list of analeptics. All medical observers are not of one opinion in 
regard to its value ; but some of them believe it (on the basis of ex- 
perience in practice) to be the best and most reliable (where it is tole- 
rated) of all recuperative medicines; not only in consumption, but in 
all other wasting diseases. 

The theory of the mode of action of cod-liver oil as an analeptic is 
an interesting subject. Dr Bennett's view of phthisis is, that the 
error of haematosis, from which tubercle results, consists in an excess 
of albumen in the blood, with a deficiency of oil ; so that, in the pro- 
cess of cell-formation, the first step of which is believed (Ascherson) 
to be the investment of oil globules in albuminous envelopes, an imper- 
fection exists, fatal to the subsequent development of the cell and 
obliging it to abort. But, the debilitation of the digestive and 
assimilative functions in phthisis renders it impossible, by ordinary 
food, to supply the desiderated oleaginous matter to the blood. Cod- 
liver oil is fatty matter which, by the assimilating action of the liver, 
following the process of digestion, is prepared/or immediate absorp- 
tion and appropriation by the blood, for purposes of nutrition. 
This rationale of its influence is, although not demonstrable, much 
more probably correct than that which refers it to the presence of 
iodine, phosphorus, or any other special ingredients which it may 
contain. Allusion to the more newly introduced dogfish oil, shark 
oil, etc., would be more proper in connection with the subject of materia 
medica than here. 

The phosphates and hypophosphites have attracted a great deal 
of attention. I do not consider the question at all settled, as yet, as to 
their value ; and do not feel competent to pronounce an opinion upon 
them. My impression, however, is, that the phosphate of iron is the 
best of them all, and that they will be found secondary and inferior to 
cod-liver oil. 

What is the proper place of alcoholic beverages or preparations in 
the treatment of chronic debility, such as that of phthisis, etc. ? 

1 Bromide of potassium promises to assume a somewhat important place in 
this list. 
9 



98 GENERAL THERAPEUTICS. 

This important question opens a discussion, only the main elements 
of which can be noticed in this work. 

In the first place, the theory of the action of agents called stimu- 
lants is almost universally misstated in authoritative treatises. It is 
commonly laid down that " one of the laws of all stimulation, whatever 
may be its degree, is, that it is followed by a depression proportionate, 
at least approximately, to the previous exaltation of the function or 
functions excited." 

The true law is this : that all stimulation which is excessive is 
followed by a depression corresponding to the excess ; while all that 
merely excites any function up to par (to use a familiar expression), 
i. e. to or toward its normal activity, does, so far, only good, with no 
resulting debilitation, however it may fail, from want of other condi- 
tions, to sustain the organ or system at the point desired. To deny 
this, would be to ignore some of the most obvious of physiological 
facts. Heat is a stimulant to life force ; oxygen to all the active 
functions ; blood is an excitant as well as food to all the tissues it 
reaches ; and all those impressions upon the exterior of the body which 
give rise to instinctive and automatic actions are stimulant, without 
any necessary ulterior depression. Nor do I see how the use of 
stimulants in any supposable case of disease could be rationally justi- 
fied, if we practically admitted the force of the law as commonly 
stated ; since if, after every dose of an excitant, the patient should 
sink as far below the condition for which he was treated, as the in- 
tended remedy raised him for the moment above it, of course a mere 
oscillation, and no advantage, must be the result. 

This, however, is theory ; which has not governed practice on this 
subject. Another interesting physiological question — "does alcohol 
contribute to the material, or to the force of the economy, or only 
excite some of its organs to exhaustive action ?" — has been the topic 
of able and learned disquisitions. I venture merely the opinion that 
it may do either of the three, or neither, according to the circum- 
stances and the quantity of its administration. When there is scarcity 
of food, or difficulty of digestion, alcohol may contribute to the needed 
material ; its carbon, hydrogen, and oxygen going to repair the adi- 
pose tissue at least. When there is excessive exertion, alcohol may 
sustain the flagging forces of the system. When given in mere excess, 
as with the intemperate, it excites to exhaustive action, organic if not 
motor ; even when the bloated body shows increase in quantity of 
material, its quality being more or less degenerate. 

In a word, then, the phrase " accessory food" is a happy one. When 
unnecessary, as in full health, alcohol is injurious precisely in propor- 
tion to the quantity used ; and the same is true in disease, when the 
quantity given is disproportionate. 

This is the important practical precept. Alcoholic stimulus should 
never be taken in quantities which produce circulatory or cerebro- 
nervous disturbance or sttper-ex citation. If this rule be observed, 
not only will it be a valuable supporting agent in phthisis and other 
complaints, but no dipsomania (methomania) or morbid thirst for it 
will arise ; that terrible disease always growing out of excess. Upon 
this principle, in the use of alcoholic beverages in cases of ordinary 
debility, the common table doses are, medically speaking, too large. 



ALCOHOL. 99 

Alcohol, in advanced or advancing consumption, in low fever, and 
in other analogous cases, when used in due proportion, is useful — 

1. By its direct excitant supporting power. 

2. By aiding the enfeebled stomach to digest a larger supply of 
food. 

3. By tending to retard tissue-metamorphosis. 

This last action is one which alcohol has been shown (Bocker. Ham- 
mond) to have, in common with other agents, used as medicines or 
luxuries; coffee, tea, morphia, quinia, etc. I have alluded to it in 
our classification of remedies, under the head ''economic medicines." 

It is not supposable, however, that the retardation of the change of 
tissue in the body is always beneficial. It may. especially in febrile 
disease, when accumulation of effete matter in the blood and organs 
is a present evil, be injurious. 

For this and other reasons, but most of all from clinical observa- 
tion, we are prepared to condemn without hesitation or qualification 
the practice introduced by the late Dr. Todd, of London (foreshadowed 
by that of the famous Dr. Brown of the last century), of giving alcohol 
as the remedy or proper medicine "for all acute diseases." Enough 
for our present purposes to cite two impartial testimonies as to the 
results of that practice. 

1. The physician whom Dr. Todd entrusted with the task of ana- 
lyzing his own records of hospital practice 1 asserts, that the mortality 
from fever in the hospital attended by Dr Todd was in a marked de- 
gree greater than that of any other fever hospital in Great Britain. 

2. Statistics of the London Hospital.' 2 recently published, show a 
large increase, since 1858, in the use of stimulants in that hospital, 
and, with it, a closely coincident ratio of increase in mortality. 

Stimulisni, as we may call the theory and practice of Dr. Todd, as 
now followed by many others, confounds three distinct propositions : 
1. That all disease is debility: 2. That all debility should be treated 
by the use of stimulants ; 3. That alcohol is always the best stimulant. 
Granting, with some qualification, the first of these, we emphatically 
deny the truth of the second and third. It is a practice which, like 
many other specialisms, will have its clay. 

The following classification of the "genuine effects of stimulation," 
when properly used as to time and dosage (remembering the often 
opposite effects of small and large doses) — is from Anstie. 3 

" I. Relief of pain. II. Removal of muscular spasm, tremor, or 
convulsion. III. Reduction of undue frequency of the circulation. 
IV. Reduction of excessive secretion. Y. Removal of general de- 
bility, or of special fatigue of muscles, brain, or digestive organs. YI. 
Removal of delirium or maniacal excitement, and production of healthy 
sleep. YII. Support of the organism in the absence of ordinary food. 
YIII. Local increase of nutrition where this is deficient." 

From the same writer comes also the following terse summary of 
the stimulating agencies most available therapeutically. 

"1. Quickly digested and nutritious/ood. 2. Opium in doses of one 

1 British and Foreign Medico-Chirurg. Review, October, 1860, p. 331. 

2 British Med. Journal. Dec. 9, 1865. 

3 On Stimulants and Narcotics ; pp. 112, 113. 



100 GENERAL THERAPEUTICS. 

or two grains ; or morphia (sulphate, &c.) a quarter to half a grain. 
3. Carbonate and muriate of ammonia, in doses of five and ten grains 
respectively. 4. Alcohol, in doses just too small to produce flushing 
of the face or sweating of the brow. 5. Chloroform, inhaled (in the 
proportion of about two per cent, to the bulk of atmospheric air) for 
a short time ; or taken internally, in doses of a few drops. 6. Certain 
foetid gum resins. 7. Many aromatic volatile oils. 8. The bitters, 
pure and aromatic. 9. Counter-irritation, as it is called ; stimulation, 
as it should be termed, through the skin." 

The subject of the treatment of debility, acute and chronic, must 
not, be dismissed without one further remark, upon the importance of 
rest in cases of exhaustion from over-exertion. The popular truism, 
that exercise is beneficial to health, has been often abased by applying 
it almost universally to invalids or valetudinarians. 

The one remedy for the immediate effects of over-exertion is abso- 
lute and prolonged repose. 

The time required for recuperation, after cerebral over-fatigue, may 
be counted rather by months than weeks or days ; and it is quite pos- 
sible for irreparable mischief to be done to the brain or spinal marrow 
by neglecting too long the demand of nature for rest. With many 
others, the author must acknowledge indebtedness to Professor Jack- 
son, of the University of Pennsylvania, for the judicious emphasis of 
his teaching upon this point. 

It is an important hygienic and therapeutic law, that exercise, to 
be beneficial, must be proportioned to the strength of the individual ; 
and must never be carried to the extent of actual fatigue or temporary 
exhaustion. 

Antidotal treatment is a topic of great interest. Its idea is proba- 
bly the oldest in medicine. Specifics always have been looked upon 
as the magna bona of therapeutical science. Unfortunately, however, 
their number, instead of increasing, has diminished under the inexora- 
ble scrutiny of modern investigation. Yet, there is room for hope that 
they may again positively increase, with the diligent application of the 
same means of observation and discovery. 

In the largest extension of the term, antidotive remedies may be 
classified thus : — 
Positive antidotes : 

Chemical palliatives ; Chemical antidotes ; 

. Antacids ; Antitoxics. 

Antilithics. Parasiticides. 

Constructive antidotes : 

Anti-periodics ; Anti-scorbutics. 

A nti-syphilitics ; 
Tentative antidotal remedies : 

A nti-arthritics ; Antiseptics ; 

Antirhe umatics / A nti-diph theritics ; 

Anti-zymotics. 
The familiar use of antacids as palliatives in dyspepsia, etc., needs 
no remark. 
Nor have we occasion to dwell, here, upon anti-lithics ; t. e. solvents 



ANTIDOTAL TREATMENT. 101 

for urinary solids, prescribed on chemical principles ; as. alkalies for 
excess of uric acid or the urates, mineral acids for excess of phos- 
phates or oxalates. 

The subject of chemical antidotes for poisons belongs to Toxicology. 

Anthelmintics are best treated of in the department of Practice 
of Medicine. (Part II.) 

Anti-psorics, or specific remedies for scabies (itch), are represented 
generally by sulphur; which, although not at all the only agent capa- 
ble of destroying the morbific acarus, is the most conyenient. Other 
cutaneous parasites (nosophyta) are also destroyed, but with less cer- 
tainty, by preparations of mercury, etc, called parasiticides. 

Of " constructive antidotes." the most important are the alkaloids 
of cinchona, applied to the treatment of miasmatic affections (anti- 
periodics). Medical men are divided upon the question whether quinia 
arrests intermittent fever, etc.. by antagonizing (chemically) the mias- 
matic poison itself in the system, or (physiologically) by causing such 
an opposite impression upon the nervous centres as is capable of sub- 
verting the condition on which the periodical or paroxysmal affection 
depends. The last is the prevailing view. But, in either aspect, the 
cure of autumnal fevers and allied affections occurring under miasmatic 
influence (neuralgias, etc.) by cinchonization, is properly called specific 
treatment ; as — 

1. No other remedies (yet discovered) have the same power. 

2. These remedies have no such control over any other diseases 
(e. g. typhus and typhoid fever, yellow fever). 

The second proposition is asserted with positiveness. notwithstand- 
ing the experimental use of quinine in full doses, by a few practition- 
ers (Dundas). in typhus and typhoid fever, and its frequent adminis- 
tration in yellow fever. 

In stating that no other medicines, yet discovered, have the same 
power. I mean, to a degree or with a certainty at all comparable to 
that of the cinchonic alkaloids. The nearest approach to this is 
afforded by arsenic. 

It is. however, a remarkable and important fact. that, when the 
recurrence of the paroxysms of intermittent fever has been allowed 
for a long period (chronic intermittent), and the system of the pa- 
tient has become debilitated and anaemic, quinine will only interrupt, 
but will not cure the disease. Iron is. then, the remedy. 

Opinion is divided as to the value or necessity of mercury as an 
anti-syphilitic. In the primary disease. I am a full believer in its 
importance; against which its frequent abuse furnishes no argument. 
In secondary syphilitic affections, especially syphilitic rheumatism, 
iodide of potassium exhibits decidedly specific powers. 

Anti-SCOrbutics are most valuable as preventives of scurvy: but 
will promptly relieve it, also, when it has occurred. All fresh vegeta- 
bles belong prominently to this class ; certain plants not so used, as 
the cactus opuntia. are included in it ; the juice of lemons, limes, etc., 
is of service for the same end, and the neutral salts of potassa have 
been largely employed, with variable results. 

Tentative antidotal treatment — for diseases in which there is evi- 
dently (as a part at least, if not the primary part of the malady) 
humoral disorder, such as gout, rheumatism, the exanthemata, etc. — 

9* 



102 GENERAL THERAPEUTICS, 

affords a large field for study and ratiocination. The positive facts, 
so far, are few ; the hypotheses, legion. 

In gout, COlchicum has long held, deservedly, the first place, as 
either an eliminative or antidotal remedy. Most observers have given 
it the first title ; J Dr. Garrod's experiments induce him to prefer the 
idea, if not the phrase of the latter. Alkaline salts of organic acids, 
as bicarbonate of potassa, soda, or lithia (G-arrod), or tartrate of 
potassa and soda, and the alkaline earth, magnesia, have also a large 
share of confidence in the treatment of gout. Experience satisfies 
me that this confidence is well founded. After all, however, so in- 
complete is any curative plan as yet devised, that a large margin is 
left for patience and opium. 

The same is true of rheumatism ; especially in its distinctive form, 
of acute articular rheumatism, or rheumatic fever. Colchicum is 
here also much given; but in the absence of the gouty diathesis, 2 
hereditary or acquired, it will generally disappoint. Alkaline salts 
are, at the present moment, the favorite tentative anti-rheumatics. 
Lemon-juice has been freely employed by some practitioners. Phos- 
phate of ammonia was for a brief time in vogue. Calomel and opium 
are still the reliance of many. Certain enfeebled cases, with free 
perspiration, will recover speedily under quininization. But in all 
these modes of treatment there is no specific certainty. The attack 
will last from one or two to six or eight weeks with all. In chronic 
rheumatism we resort, with the same hope, to guaiacum, spirits of 
turpentine, iodide of potassium, cod-liver oil ; but often our hope is 
much lengthened out. Of propylamin, a remedy for rheumatism im- 
ported not long since, I have had some experience, and have no basis 
for a favorable opinion. The search for and trial of such remedies is, 
however, certainly altogether legitimate. 

In the management of the zymotic affections, the only great triumph 
of medical art has been one of prevention. Vaccination affords an 
instance of effectual control over one of the most destructive and 
loathsome of pestilences, by the interference of the physician. As to 
the treatment, even of smallpox 3 itself, when it has occurred, and of 
scarlet fever, measles, chicken-pox, hooping-cough, and mumps, we are 
forced to confess our powerlessness, except to conduct the case, by 
the aid of palliative measures, to its natural and spontaneous termi- 
nation. 

1 Colchicum has been shown, by Krahmer and Hammond {"Proceedings of 
Biological Department of Acad, of Nat. Sciences of Philadelphia, Nov. 1st, 
1857), to increase tlie amount of the solids of the urine, more decidedly than 
any other vegetable diuretic. 

2 Garrod insists on the diagnostic importance of the uric acid test for gout. 
It is easily applied, as follows : Take about fsjss of the serum from a blister, 
or from the blood drawn by venesection or cupping, and place it on a flat dish 
or watch-glass. Add to this fifteen drops of acetic acid, and place in it two or 
three threads of cotton. Allow the glass to stand in a warm room for one or 
two days, to evaporate. If the cotton fibres be then removed and examined 
microscopically with an inch object-glass, they will be found, if the serum con- 
tained uric acid, to be covered with its crystals, arranged somewhat as the 
crystals of sugar-candy form on a string. 

3 Sarracenia has proved valueless upon fair trial. 



SULPHITES 103 

This m equally true of yellow fever. There is no specific 
known for this terrible disease. Quinine, mercury, etc. have failed id 
the hour of need too often to be relied upon. It is to be palliated, 
as it cannot he cut short. 

Nor have we any specific for epidemic cholera. Anti-spasmodics. 
at very short intervals of administration, and ice. with free external 
stimulation, will conduct many cases to a successful close : but this is 
not antidotal treatment. I am fully satisfied that calomel in true 
epidemic cholera, is altogether useless. 

In the medication of zymotic affections having, as a local symptom, 
inflammation of the mucous membranes, with unusual tendency to 
(septic) decomposition or disorganization, — c g. scarlatina and 
diphtheria. — chlorate of potassa and other preparations of chlorine, 
as tincture of chloride of iron, have achieved recently a very wide- 
spread reputation. 

The last-named of these medicines, the tincture of the chloride of 
iron, appears also to have an excellent effect (although we can hardly 
call it antidotal; in asthenic erysipelas. 

Ant i-cWphtheritic power has of late been strongly asserted of Ume- 
water locally applied. 

Professor Polli, of Milan, has. not long since, proposed the internal 
use of the sulphites of soda. lime, and magnesia, in toxemic diseases. 
as antizymotics or antiseptics. The chemical rationale of their action 
is very plausible. Success is already asserted 1 for them in pyaemia, 
etc.. and in glanders in the horse. As a tentative practice it is worthy 
of careful trial. 

With the view of encouraging such trial,, the following account of 
the treatment is given : — 

Dr. Giovanni Polli. of Milan, in 1864, communicated to the Eoyal 
Institution of Lombardy his researches and experiments upon the in- 
fluence of materials taken into the body upon it? morbid and destruc- 
tive changes. Believing that, in all zymotic diseases, two mc 
elements must exist, the "ferment" and the fermentable material, he 
endeavored to ascertain how. if we cannot destroy the morbid poison, 
we may at least arrest or retard the decomposition it produces. Many 
agents which check fermentation and putrefaction are not safe as 
medicines. Sulphites and hyposulphites of alkalies and alkaline earths 
prove, upon trial, to be so. 

First. Dr. Polli experimented upon dogs : saturating their bodies, 
through the stomach, with sulphites, and then killing them. They 
were exceedingly slow in undergoing decomposition. Then, he inocu- 
lated several with mucus of glanders, putrid blood, and unhealthy pus, 
and dosed some of them with sulphites, others not. Those so dosed 
suffered much the least severely. 

So encouraged, he extended his experiments to human beings. 
"Without detail, it may be said that he satisfied himself and fellow 
practitioners of the safety of sulphites and hyposulphites of mag- 
nesia, soda., and lime, as medicines : and of their exhibiting a b 
ful degree of power in mitigating and even sometimes arresting 

1 See Amer. Journal of Med. Sciences, Oct., 1S63 ; and later numbers of the 
same Journal. 



104 GENERAL THERAPEUTICS. 

septic diseases. Such experiments are well worthy of extended, care- 
ful and systematic trial. Thus it is that science should suggest reme- 
dies for experience to prove ; empiricism may thus be made rational, 
and rationalism in medicine become practical. Even if disappoint- 
ment attend a certain set of experiments, or the trial of a particular 
remedy, such a trial is fully justifiable in its principle. 

Justice to Dr. Polli's ideas and inquiries calls for a clear recognition 
of what he does assert as matter for experimental practice. He claims, 
for instance, that intermittent fever is cured by sulphite of magnesia, 
an ounce or an ounce and a half in 24 hours, in divided doses ; that 
the attack is not cut short as by quinine, but that the symptoms are 
gradually diminished ; but, that it cures the disease more completely, 
and in a greater number of cases, than quinine does. It is asserted 
that mitigation of symptoms is observed in pyaemia, scarlet fever, 
diphtheria, and other acute febrile disorders, under the sulphites ; and 
that in cattle-plague, one third attacked recover under their use. 

The sulphites appear in the urine about twenty minutes after they 
are taken ; also in the sputa and saliva; but they are gradually changed 
in the system into sulphates. M. Carey Lea, of Philadelphia, in a 
paper published in 1865, l reports a series of careful experiments, in 
which he found evidence that when a small quantity of sulphite or bi- 
sulphite of soda is taken, less than a hundred grains, it disappears by 
oxidation in the system ; but if large amounts be ingested, a consider- 
able portion passes unchanged in the urine, and sulphurous acid may 
even be detected in the breath. 

Polli asserts that the sulphites are not usually decomposed in the 
stomach. If they are, sulphurous acid gas is evolved. A little mag- 
nesia should then be added to each dose to 'correct this effect. The 
tolerance of the sulphites and hyposulphites is greatest when they are 
freely diluted. They are decomposed by all vegetable acids. Lemon- 
ade, for instance, should not be given to a patient using them. 

Hyposulphite of soda is much more purgative than sulphite of soda 
or magnesia ; those salts are commonly rather diuretic. If cathartic, 
it is without pain. The stools are without fetid odor under the use 
of these remedies. Dr. Polli recommends especially the sulphite of 
magnesia, as the most active and having the least taste. The dose is, 
according to him, fifteen to thirty grains, in powder dissolved in water 
or an aromatic vehicle, or in troches. He advises saturating the system 
with the medicine ; four or five drachms daily for an adult as a mini- 
mum. Five to seven drachms of the sulphite of soda are borne well. 
Polli prefers the sulphites for rapid curative action in acute diseases ; 
the hyposulphites for prophylaxis. Their long continued use may 
bring on oedema and diseases of debility ; otherwise, they show no in- 
fluence on the system. 

Externally, solutions of the sulphites, especially when mixed with 
a portion of glycerine, are recommended as applications to suppurat- 
ing surfaces, to sloughing and ulcerated parts. Sulphites of lime and 
magnesia are somewhat caustic. In septsemia from wounds, &c, Polli 
administers thirty grains of the sulphite of magnesia, every two hours, 
internally. 

1 Am. Journ. Med. Sciences, Jan., 1865, p. 84. 



ALTERATIVE TREATMENT. 105 

Chemically, the formula of hyposulphite of soda is given by Pereira 
as NaO,S 2 Oy That of sulphite of soda is stated as XaO,S0 2 4-3HO. 
Dr. G. B. W ood, in the last edition of his Practice, mentions chiefly 
the bisulphite of soda. H. R. De Ricci, on the ground of experience, 
insists upon the use of the sulphite of magnesia, in scruple doses, early 
in the cases treated. 

To show the presence of sulphurous acid in the urine, Dr. Davy 
half fills a test-tube with the urine, slightly acidulated with muriatic 
acid, and suspends in the tube, above the urine, a piece of starched 
paper stained blue with a weak solution of tincture of iodine. If sul- 
phurous acid be present, its evolution will decolorize the paper. 

En r6sn,m6, we may say that all endemic, epidemic, infectious, and 
contagious diseases are naturally self-limited ; and that, so far, we 
have only reached a certainly curative treatment for one class, — viz. 
intermittent, remittent, and pernicious (classed together as miasmatic) 
fevers ; and a preventive treatment for another, smallpox. 

While, therefore, for yellow fever, scarlatina, pertussis, etc.. we are 
without the possession of any specific or antidotal treatment, the pal- 
liative plan is the one for us to pursue. All attempts, by violent 
measures, to cut short either of these diseases, while they fail to at- 
tain that object, will endanger the patient, by lowering his forces, and 
thus promoting the victory of the depressive toxemic cause. 

Yet, I repeat, we are not to abandon or reject the hope that obser- 
vation and cautious experiment, guided by the lights of advancing 
science, will enable us hereafter to discover remedies as potent in the 
management and control of scarlet fever, yellow fever, and cholera, 
as quinine is in that of ague, or vaccination in the prevention or salu- 
tary modification of smallpox. 

Alterative treatment is distinguished, in our classification, it may 
seem arbitrarily, from the antidotive. All antidotes may be said to 
be alterative, but all alterative medicines are not antidotal ; as the 
latter expression implies at least the probable, if not the known ex- 
istence of a material cause, against which the antidote is to act. 
Yet the distinction is not one upon which we can insist, although it 
appears convenient. 

The term alterative is by no means a mere apology for ignorance ; 
it involves an important therapeutical principle ; viz., the supplanting 
or displacing of a morbid impression, condition, or process in the body, 
by the safer impression and counteraction of a medicinal agent. The 
influence of the latter, physiologically speaking, may be, per se, abnor- 
mal; yet, having a sanative purpose, it is therapeutic. 

This principle may be sufficiently illustrated by allusion to two or 
three examples. In the peculiar and often violent inflammation of the 
throat in scarlatina, the free application of a strong solution of nitrate 
of silver to the part will almost invariably arrest (if used early) the 
morbid process : converting it, at all events, from a specific and danger- 
ous into a simple and mild phlogosis. 

So will the powerful impression of the solid nitrate of silver, or other 
caustic, upon the surface of the penis affected with chancre, supplant 
the venereal process, and leave in its place a benignant ulcer. 



106 GENERAL THERAPEUTICS. 

When erysipelatous inflammation is spreading like a conflagration 
from part to part, a blister or tincture of iodine, etc., will form a 
cordon sanitaire, by inducing its own milder irritation in advance of 
the disease. 

The most essential part of the treatment of chronic diseases of the 
sTcin, is either alterative or antidotal. Parasitic affections, as scabies, 
favus, mentagra, etc., require the destruction «of the epizoon or epi- 
phyte by an antidote. Others, as eczema, lichen, impetigo, lepra, etc., 
when at all obstinate, are treated in the same manner essentially, to 
whichever class the disease may belong. Why ? Because the principle 
is .the same in all — the alterative principle. The abnormal, perverted 
nutrition of the cutaneous tissue, whether it be deeply or superficially 
affected, is (apart from antiphlogistic or sedative treatment, called for 
in some cases) to be subverted, by a decisive change in all its condi- 
tions ; and, speaking boldly, it is little matter what change, so it be 
considerable. Any means which will hurry the removal of the old, 
diseased skin, and favor the immediate construction of a new layer, 
will be curative, whether it be only soap, water and frictions, mercu- 
rial ointment, vesication, or the actual cautery. And the same prin- 
ciple explains and justifies the internal use of arsenic and mercury in 
the management of so many very diverse forms of cutaneous disease — 
the indication for alterative medication being the same in all. 

The administration, for long periods, of minute doses of powerful 
alterative medicines, in the treatment of chronic affections which 
resist other management, is less common now than formerly, on ac- 
count of the explosion of some old hypotheses connected with it. It 
is very possible that in this, as in some other medical reforms, we may 
have gone too far. 

Agents which tend with any degree of constancy to increase the 
rate of metamorphosis of tissue in the body, are few. It is well 
known that most of the diuretics given for the removal of dropsical 
accumulations (a treatment often carried to an irrational excess), 
increase only the fluid secretion of the kidneys, affecting little or not 
at all their solid excreta. But there is good reason to believe that 
potassa and soda, and some of their compounds, as well as iodine and 
mercury, do hasten the disintegration of tissue. Iodide of potassium 
has been shown, by Melsens, to be in this way eliminative of lead, laid 
up in some organ (probably the liver), removing it in the shape of 
iodide of lead. 

If any possible measures, beyond attention to hygiene and #epose, 
can benefit cases of organic degeneration, we might hope for advan- 
tage from the combination of tonics or analeptics with alteratives. 
Dr. Chambers (on Digestion and its Derangements) remarks thus : — 

" In Bright's disease I know of no treatment so advantageous as 
that which unites alteratives (that is, liquefacients of tissue) with 
those restorers of blood par excellence, iron and animal food." 

Iodide of iron, or iodide of potassium at the same time with cod- 
liver oil, may afford an example of this sort of medication in its sim- 
plest form. Its object is, to favor the rapid removal of old tissue, and 
the formation of good new structure in its place. 

Whatever produces ft powerful impression, not immediately destruc- 



ELECTRICITY. 107 

live, upon the system, may act alteratively, and sometimes beneficially, 
in chronic disease. 

Thus, electricity, perse veringly used, in certain cases of paralysis 
and other neuroses, does more than anything else. 

At present, while it is clear that electricity must be capable of 
powerfully influencing the human system, our knowledge of its uses 
is far from complete. Rash experimentation with it may do harm ; 
but all its appliances may be so graduated as to admit of the mildest 
and most cautious tentative practice. 

Three agencies are included under the term electricity. 1. Static 
or frictional electricity, of the machine, of glass and revolving rubbers. 
2. Galvanic electricity, or the continuous current of the battery, of 
metals with acid solutions, &c. 3. Faradization, by induced and in- 
terrupted currents, electro-magnetic or magneto-electric. 

Frictional electricity is least in use. It is best employed by placing 
the patient on an insulated stool (with glass legs or feet) and charging 
him from either a plate or a cylinder machine ; then withdrawing the 
electricity by & pointed metallic conductor if a mild and general effect 
is wanted, or by a round one of some size to produce sparks and a 
locally stimulant effect. 

Galvanic electricity is developed by chemical action. A battery 
consists of a series of plates of two materials (copper, zinc, silver, 
carbon, <fcc.) in alternation, a liquid in contact with which acts more 
upon one than on the other. Daniell's and Smee's batteries are espe- 
cially recommended. Althaus prefers a modification of Daniell's. in 
which, with copper and zinc plates, a solution of sulphate of copper 
is used as the liquid. This will run for six months without cleaning ; 
with cleaning, for a much longer time. The size of the cups determines 
the quantity of the current of electricity; the number of cups, its 
intensity. Quantity is especially powerful for chemical action ; in- 
tensity, for overcoming the resistance of a slowly conducting medium. 
The direction of the current, through the wire or wires connecting 
them outside of the liquid, is, in ordinary batteries, from the copper 
(or platinum, silver, or carbon) to the zinc ; the former being the 
positive and the latter the negative pole. 

Faradaic or induced electrical currents are usually obtained in either 
of two modes. 1. By galvanic electricity (from chemical action) 
acting upon iron ; making it magnetic during the closure of the 
circuit, which is interrupted momentarily, by a vibrating spring. A 
current is thus induced, in one direction at the moment of closing, and 
in the opposite at the opening of the connection. 2. By causing a 
magnet or its keeper of iron to revolve so as alternately to approach 
and recede from contact. A helix or coil of wire, wound around the 
magnet, will then have an induced current at the moment of approach 
and at that of separation. This is more convenient and manageable 
than any other sort of apparatus ; but some authorities claim greater 
power for electro-magnetism in therapeutics. It is asserted also 
(Althaus) that the constant galvanic current (as of Daniell's, Grove's, 
Bunsen's, or Smee's batteries) has a more extended or general stimu- 
lant or alterative effect; while the interrupted (faradaic) current is 
more powerful locally. Proof of the difference between the two 
may be obtained by applying them in succession to the face. The 



108 GENERAL THERAPEUTICS. 

continuous current produces a flash of light by its influence upon the 
retina. The interrupted causes the muscles to contract in proportion 
to its force. Remak has greatest confidence in the continuous current. 

Duchenne, of Bologne, a high authority, asserts as the conclusion 
derived from his experience, the following : — 

" In man, whatever may be the direction of the currents, or the 
degree of vitality of the nerves they traverse, the same results are 
always produced when the conductors are applied to any part over 
the course of the nerves — namely, muscular contractions and sensa- 
tions. 

" Various changes in the current-direction produce no appreciable 
influence over the sensibility, or capability of voluntary muscular con- 
traction, in man." 

On the basis, however, mainly, of Dubois Reymond's experiments, 
other electricians insist that a current towards the centres of the 
body stimulates the sensory nerves, while it lessens the excitability of 
the motor nerves ; and that a current from the centres out to the peri- 
phery stimulates motor and acts as a sedative to sensory nerves. 
Pereira says, " in paralysis of sensation only, the current should be 
direct or centrifugal. In paralysis of motion, it should be inverse or 
centripetal. In paralysis of both sensation and motion, the vibrating 
current (faradization) is peculiarly appropriate ; for by this the sensi- 
tive and motor nerves are alternately excited, while the one current 
promotes the restoration of the excitability, which may have been 
lessened by the preceding current." 

The precautions needful in trying electricity as a remedial appli- 
cation are — 

1. Always to begin with it very gently, watching carefully its effects ; 
continuing it therefore at first but for a few minutes at once. 

2. To be especially careful in its use at or near the great nerve- 
centres, as the brain and spinal marrow. 

3. Avoid using it, even locally, during the existence of an inflam- 
mation or acute irritation of the spinal marrow or brain. 

The idea which Dr. Radcliffe has especially advocated, of using 
galvanism, e. g. in neuralgia, or convulsions, with such force as to par- 
tially or temporarily paralyze a disordered nerve-centre, is, I am sure, 
unsound in theory and very unsafe in practice. I would not think of 
resorting to such a measure in any conceivable case. 

The affections in which electricity, in various modes of application, 
has been found most positively and frequently serviceable, are — 
paralysis, especially hysterical, reflex, 1 and lead palsy ; aphonia, and 
diphtheritic paralysis of the throat; neuralgia, chronic rheumatism, 
amenorrhea, suppression of lactation, and cancerous or other tumors. 
In surgery, galvano-puncture is resorted to for aneurisms, &c. In 
treatment of asphyxia narcotic coma, &c, its powerful stimulation is 
sometimes an important means of saving life. 

Hydropathy is an example of a most valuable agent misapplied by 
exclusivism, which is always quackery. That is, it is quackery to 
deny the virtues of all other remedies, no matter how long or well 
established, in extolling those of one, made the sole panacea of prac- 

1 See Mitchell, Morehouse and Keen, upon Wounds of Nerves, &c. 



HOT AIR-BATHS. 109 

tice. Bathing, local and general, douches, and even packing in the 
wet sheet, are. used with judgment, potent alterative and often sana- 
tive means. Almost hopeless chronic cases, of nervous disorders, dys- 
pepsia, chronic rheumatism. &c. may sometimes have their languid 
vitality aroused by the revolutionizing action of such processes. The 
danger is, of unprofessional and ill-judging abuse of an agency of such 
power. 

Hot air-baths have lately attracted attention. 

M. Fillet, 1764 and Fordyce, Blagden, and others, 1775, proved, as 
Chabert the '-Fire King" also illustrated, that a dry air heat above 
that of boiling water can be borne by the human body with safety. 
Within a few years the use of the hot air bath, similar to that of the 
calidarium of the ancient Romans, has been introduced for remedial 
purposes. It is misnamed the " Turkish Bath," as the latter is a 
vapor bath, at a temperature below 100°. 

Erasmus Wilson, the dermatologist. Mr. Urqubart, Sir John Fife, 
and others in England, have, upon personal experience, lauded highly 
the virtues of the hot air bath. The requisites are, a heated metallic 
surface (a common stove will do) to warm the air of the apartment, 
and an adjoining convenient water bath, with warm or cool water, to 
plunge into after or alternately with the air bath. 

Mr. Urquhart thus speaks of its use in health : ,; When I come v >^ 
back to it after its absence and the use of other baths, even the best. 
it is like getting on the back of a thorough-bred after having to ride a 
cart horse. It is of service at every moment and at all temperatures. 
You come in from a journey, say before dinner ; you go in not heated, 
when it may stand at 120° ; you dress at that charming temperature, 
with streams of hot or cold water, or the tank to revel in. So, also, 
you may dress in the morning. My regular practice, when not re- 
quiring it for health's sake, is to go in on getting up and on going to 
bed. dressing and undressing there ; five to ten minutes suffice to bring- 
on the flow of perspiration. After that, a plunge in the cold water, 
and you come out fresh, glowing with a sense of cleanliness, health', 
and strength, which no other operation can convey to the body. You 
are then indifferent to the heat of summer and the cold of winter." 

Copious perspiration, and the thorough removal of the effete cuticle, 
as well as of all foreign impurity, from the surface of the body, are the 
obvious and direct effects of the hot air bath. Depuration and func- 
tional balance of the excretory processes are thus promoted ; while 
the stimulant influence of heat, so often useful in cases of depressed 
vitality, is obtained. Renewal of the nutrition of the skin must also 
be more rapid under such a process. The temperature is made to 
vary between 120 c and 200° ; 130° to 140° would be a good standard. 

The diseases in which the hot air bath has been tried with 
favorable results, in cure or palliation, are, especially, acute and 
chronic rheumatism, lumbago, sciatica, neuralgia, gout, dropsy, 
catarrh, influenza, throat affections, diarrhoea, dysentery, sluggishness 
of circulation, disorders of the liver, scrofula, incipient phthisis, 
Blight's disease, ague, obstinate skin diseases, chorea, mania ; also, 
it is said, even cholera and hydrophobia. 
10 



110 GENERAL THERAPEUTICS. 

Mustard Bathing.— Dr. S. NewingtoD, of England, ascertained 
by experience in his own person that the extensive and continued 
application of mustard to the body is a powerful tranquillizer of ner- 
vous excitement and means of restoration of the balance of a dis- 
turbed circulation. Use of the same remedy with a number of 
patients has confirmed its value. One mode of its application is as 
follows : Two handfuls of powdered mustard are tied in a cloth and 
placed in hot water, then squeezed in the hand until the strength of 
the mustard has been extracted. A thick towel, long enough to 
reach around the loins, is then wrung out of this infusion, wrapped 
round the body, and covered with a large piece of oiled silk, or gum 
elastic cloth. Another plan is that of the mustard bath ; that is, an 
ordinary warm bath into which have been thrown five or six handfuls 
of mustard. 

In maniacal excitement, particularly, these applications have been 
found usefully sedative. Sleeplessness, from any cause, may be so 
treated ; as well as hysteria, etc. It may be expected that such a 
process will be useful also in promoting reaction in cases of internal 
congestion ; perhaps, in the chill of pernicious fever, in "spotted fever," 
and the incipient collapse of cholera. 

Movement-cure (kinesi-paihy) is a name for another kind of practice 
(Taylor) founded upon the teachings of Ling, of Sweden ; consisting 
of passive exercise of the muscles, for the purpose of improving the 
circulation, innervation, and reparative nutrition of diseased and en- 
feebled organs. 

Although an elaborate system of particular movements upon a quasi- 
physiological rationale, has been devised, adapted to each kind of 
chronic local or general disorder, careful examination of the treatise 
of an authority upon the subject convinces us that this is all surplus- 
age. What remains to be true is, that, where active exercise is not 
practicable, systematic frictions and passive movements of all parts 
of the body are very useful in its stead. What is added to this by the 
specialist is, faith on the part of the patient, and perseverance in the 
attendant ; two things which, without extraordinary processes, explain 
much, and account for many cures. 

Under any treatment, however, we must not encourage sanguine 
hopes in any instance of organic degeneration, the origin of which 
is, so generally, to be found in a failure of systemic vital power. The 
physician will do much for his patient, if he can persuade and instruct 
him to adapt his living to the actual condition of his physical resources, 
so that, whether his malady be B right's disease of the kidney, diabetes 
mellitus, cirrhosis of the liver, or fatty or other organic disease of 
the heart, he may economize both the material and the force of his 
system, by such a regimen of diet, exercise, and excitement as his 
state requires. 

With such management, it often happens that valetudinarians live 
longer than those who, with sound constitutions, are less watchful 
against causes of disease, and less prompt in taking warning from the 
slightest symptoms or approaches of ill health. 

Nor need we look upon the failure of medicine to arrest the process 
of organic degeneration as a subject of very humiliating discourage- 



INHALATION AND ATOMIZATION* Ill 

ment. As death is the natural result of life, in the human organism 
as in every other material form, this partial death occurs, also, under 
physiological laws ; and, if it be premature in certain instances, we 
may believe that this, too, may be traced to a near or remote causa- 
tion, in perfect harmony with the highest interests, moral as well as 
physical, of man. 

INHALATION AND ATOMIZATION. 

Although the ancient Egyptians had some knowledge of the effects 
of drugs whose vapors were inhaled, and Hippocrates, Galen and other 
Roman physicians, as well as, later, the Arabians, so employed them, 
they were afterwards long lost sight of. Bennet, of London, in the 
seventeenth century, seems to have been the first in modern times to 
use inhalations systematically. The earliest proper instrumental 
inhaler, was probably that of Dr. John Mudge, an English physician, 
invented and applied in 1799. St. John Long, the charlatan, used 
large inhalers, from which a number could breathe at once. Boer- 
haave and Yon Swieten, in the early part of the eighteenth century, 
employed medicated inhalations. Scudamore, in 1830, issued a work 
upon the subject which had a wide circulation. 

Since that time, an immense amount of experimentation has been 
made, to ascertain what local effects upon the lungs and air-tubes, and 
what action upon the system at large, might be obtained by vapors 
brought in contact with the highly absorbent respiratory membrane. 
Most important of all, of course, was the discovery of gaseous anaes- 
thesia by Sir Humphrey Davy, and the subsequent practical appli- 
cation of it by Morton. Ether, chloroform and nitrous oxide now 
take their places not only as alleviators of pain during operations 
and in parturition,, but, also, as occasionally valuable aids to the phy- 
sician in medical cases. Extreme neuralgic pain is sometimes treated 
by the inhalation of ether or one of the other anaesthetics. Convul- 
sions are not unfrequently so treated ; and, in those at least of a hys- 
terical or merely irritative character, with good success. 

For medical as well as surgical use, chloroform is the most prompt, 
quiet and effectual anaesthetic. In cases of disease, it does not need 
to be so given as to produce the total relaxation of profound anaes- 
thesia. Can its use be justified, in view of the fact that a considera- 
ble number of deaths have been traced to it? 

Without space to discuss this point, I may say that observation of 
the use of chloroform, in a method employed by some of the surgeons 
of the U. S. army during the war, has modified my previous appre- 
hension of it. The great necessity is, as Dr. Sansom 1 has shown very 
fully, the dilution of the chloroform with abundance of air, and its 
gradual introduction. Most methods exclude air too much. That 
which I have alluded to above is, letting the chloroform fall, drop by 
drop, upon a handkerchief spread singly over the face of the patient. 
An instrument is used for the dropping, which will allow only one drop 
to pass at once. I believe that, with this or any other mode of abun- 
dant dilution and slow inhalation of it, watching momentarily its 
effects, chloroform is safe, in an immense majority of cases. 

* On Chloroform ; its Action and Administration. 



112 GENERAL THERAPEUTICS. 

Ether excites some persons too much to be generally relied upon in 
medical cases. Two or three parts of ether with one of chloroform 
make a mixture, often used with advantage. Nitrous oxide, although 
experimented upon by Davy and used by Wells before ether, has only 
of late come to be highly appreciated for practical use. Its appli- 
cations by inhalation in disease remain to be tried and studied. 

Apart from the " anaesthetics," it cannot be said that great success 
has ever been obtained in the cure of diseases by inhalation. Pallia- 
tion of pulmonary and bronchial or laryngeal irritation, or diminution 
of excessive expectoration, as by simple vapor of water, tar-vapor, or 
that of infusion of hops, opium, &c, has been often realized. With 
other aims and agents, disappointment has generally predominated. 
- For ordinary inhalation, very simple apparatus will suffice. For . 
instance, a wide-mouthed jar or bottle, with a cork in it; the cork 
pierced by two glass tubes, one straight, and reaching to near the 
bottom of the bottle ; the other short, and bent outside of the cork, 
The bottle is to be not quite filled with the liquid (more or less heated 
according to its volatility) ; the bent tube not reaching its surface, the 
other conveying air into it from beyond the cork. Even this is not 
necessary, in the case of liquids used with water, at least. We may 
employ these by pouring boiling water into a convenient vessel of any 
kind, the medicament being added to it, and then, covering the vessel 
with a towel, holding the mouth and nostrils under the edge of the 
latter. Hops, in infusion, or stramonium leaves, or laudanum, &c, 
may thus be used. Of laudanum, e. g., twenty or thirty drops may be 
put in a pint of water, for very worrying cough. Smoking is a primi- 
tive method of inhalation. Tobacco, so used, sometimes relieves iu 
asthma ; but cigars of stramonium leaves, or of paper saturated with 
nitrate of potassa, are more effectual in the paroxysms of the same 
disorder. 

Recently, first by Sales Girons, extremely minute division or atomi- 
zation of liquids, so introduced into the air-passages, has been sub- 
stituted for inhalation. Under the natural fascination of novelty, and 
the imposing appearance presented by instrumental appliances, it is 
quite probable that a degree of enthusiasm exists now about it, 
more than will be permanent. Still it is an important addition to 
our means of treatment of affections of the throat, and, perhaps, of 
some of those of the lungs. Referring the reader to special works 1 
upon it for details, I must give only the briefest account of atomiza- 
tion or nebulization. 

The essential idea of it is, the forcing of a fine jet of liquid against 
either a solid body, or a strong current of air, so as to convert it at 
once into diffused spray. Bergson, for instance, employed the tubes 
used for odorators, that is to spread perfumed liquids in the air. Two 
glass tubes with minute orifices are fixed at right angles to each other, 
so that the end of the upright tube is near and opposite to the centre 
of the orifice of the horizontal tube. The upright tube being im- 
mersed in the liquid to be nebulized, air is forcibly blown through the 
horizontal one. The current of air, so passing over the outlet of the 
tube communicating with the liquid, rarefies the air in the latter, 
causing a rise of the liquid in the tube, and its very minute subdivision 

1 See Da Costa, On Inhalation. 



INHALATION AND ATOMIZATION. 113 

(atoinization, nebulization. pulverization), as it escapes Silver tubes 
may be used instead of glass, but are harder to keep clean. Glass 
ones may be cleaned with muriatic acid solution, aided by a bristle to 
remove obstructions. The form of the tubes may be varied, so as to 
allow of their application to any part of the body. 

Kichardson's spray-producer (designed for local refrigeration) is 
constructed upon a similar principle. It consists of a graduated bottle, 
through whose cork passes a double tube ; that is, a tube within a 
tube. The inner one reaches to near the bottom of the bottle, below, 
and above to near the extremity of the outer tube. The latter has 
entering it, above the cork, another tube connected with " hand bel- 
lows," — or, two elastic bags, the one nearest the bottle (protected by 
silk network) acting as an air-chamber, and the farthest one being 
compressed by the hand to produce a jet of air into the bottle aud 
tube. 

Siegle devised an apparatus for the application of steam-power to 
atomization. The tubes being arranged upon Bergson's principle, a 
small boiler is connected with the horizontal one, and in the boiler 
steam is generated by the heat of a spirit lamp. The jet of steam 
from the horizontal tube nebulizes the liquid drawn up from the ver- 
tical tube immersed in a vessel containing it. Various modifications 
of this have been made. 1 Though the steadiness of action of the 
steam-apparatus must be a great advantage, for many purposes the 
hand-ball atomizer must be. more available. 

For full effectiveness of any method of inhalation, in chronic or 
subacute cases, the patient must have the instrument at his own 
house, learn its management, and use it with regularity for a sufficient 
time. This of course must limit very much the employment of such 
medication. 

The first inhalations should always be short, and with warm water 
only, to inure the patient to their use. The distance of the mouth 
from the tubes may vary from six inches to two feet. When prepared 
for it, one may inhale " medicated spray" for ten minutes at a time ; 
breathing deeply if we wish the liquid to reach the remoter air pas- 
sages. It should never be done after a hearty meal ; and the patient 
should remain in doors for a while after the operation. 

Proof has been obtained that atomized liquids inhaled do, sometimes 
at least, pass down into the trachea ; constantly, into the larynx. It 
is probable, indeed almost certain, that a certain portion may even 
reach the lungs. As to their application, trial has been and is now 
being made of this process especially in croup, diphtheria, oedema of 
the glottis, catarrh, chronic laryngitis, hooping-cough, asthma, pulmo- 
nary hemorrhage, and phthisis. 

False membrane has been asserted by Kuchenmeister, Biermer, 
Geiger, and others to be dissolved, or at least removed from the throat, 
by inhalation of hot lime-water. Dr. Geiger' s method is to make the 
patient breathe the vapor arising from hot water poured on unslaked 
lime. 

From Dr. Da Costa's monograph upon inhalation I cite the folio w? 

1 G-emrig, of Philada. , Br. W. Reed of Boston, and Codman and Shurtleff 
of Boston furnish improved forms of apparatus for atomization, 

10* 



114 



GENERAL THERAPEUTICS, 



ing conclusions, as indicating the present state of experience upon 
the subject: — ' 

" That in most acute diseases of the larynx, and still more so in 
acute disorders of the lungs, the value of inhalations of atomized fluids, 
save in so far as those of water may tend to relieve the sense of dis- 
tress, etc., and aid expectoration, is very doubtful; though in some 
acute affections, as in oedema of the glottis and in croup, medicated 
inhalations have strong claims to consideration. 

" That in certain chronic morbid states of the larynx, particularly 
those of a catarrhal kind, and in chronic bronchitis, they have proved 
themselves of great value. 

" That in the earlier stages of phthisis, too, they may be of decided 
advantage, and that at any stage they may be a valuable aid in treat- 
ing the symptoms of this malady. 

"That their influence on such affections as hooping-cough and 
asthma is not satisfactorily proven. 

" That they furnish a decided and unexpected augmentation of our 
resources in the treatment of pulmonary hemorrhage. 

" That they require care in their employ ; and that in acute affec- 
tions we should consider whether, as they have to be used frequently 
to be of service, the patient's strength justifies the disturbance or the 
annoyance their frequent use may be." 

DOSES FOR INHALATION. 3 

Alum 
Tannin 

Perchloride of iron . 
Nitrate of silver 
Sulphate of zinc 
Chloride of sodium . 
Chlorinated soda 
Chlorate of potassa . 
Muriate of ammonia 
Watery extract of opium 
Fluid extract of conium 

" " hyoscyamus 

Tincture of cannabis indica 
Lugol's solution of iodine 
Fowler's solution of arsenic 
Tar water 
Oil of turpentine 

HYPODERMIC MEDICATION. 

Apparently upon a suggestion contained in Valleix's work on Neu- 
ralgia, Dr. Alexander Wood, of Edinburgh, in 1843, experimented 
successfully with the injection of anodynes under the skin of parts 
affected with neuralgic pain. Dr. Kursack, of Vienna, disputes 
priority with him. Mr. Rynd, of Dublin, followed him about a year. 
Local effects, only, seem to have been clearly recognized by these 
gentlemen. Mr. C. Hunter, in 1858, proved that general effects upon 



10 to 20 


grains. 


1 to 20 


a 


i to 2 


a 


lto 10 


a 


lto 6 


a 


5 to 20 


u 


£ to 1 drachm. 


10 to 20 


grains. 


10 to 20 


u 


-± to i 

4 LU 2 


it 


3 to 8 


minims. 


3 to 10 


<( 


5 to 10 


n 


2 to 15 


a 


] to 20 


tt 


1 to 2 drachms. 


1 to 2 


minims. 



Op. citat., p. 40. 



From Da Costa. 



HYPODERMIC MEDICATION. 



115 



the whole system are produced, in whatever part of the body the in- 
jections are made. Since 1855, however, many medical men have 
studied the subject ; especially B6hier, Lorent, Eulenberg. and Xuss- 
baum abroad, and Ruppaner in this country. The practice has now 
become quite common. 

It has been amply proved that hypodermic injection of medicinal 
substances is ordinarily entirely safe; more rapid, certain, and exact 
in proportion to the amount, in its effects than medication by the 
mouth ; that it requires one-third or one-half of the quantity necessary 
when given by the stomach, and produces less complicated and gen- 
erally less inconvenient results. 

The medicines mostly used in this way are narcotics, sedatives, and 
nervine tonics. It is in diseases or symptoms affecting the nervous 
system that the greatest number of successful cases has been reported. 
Pain, most of all, is speedily conquerable by it. Hunter lays down 
the indications for it thus : — 

"When the immediate and decided effect of the medicine is required. 

" Where medicines administered by the usual methods fail to do good. 

" Where the effect of a medicine is required, and the patient refuses 
to swallow. 

" Where, from irritability of the stomach, or other cause (such as 
idiosyncrasy, etc.), the patient cannot take the medicine by the 
stomach." 

The following Table is slightly modified from Hunter's : — 



' Locally with 



The injection of 
medicines into 
the cellular 
tissue beneath 
the skin may 
be made 



\i 



Caustics, for naevi, aneurisms, &c 
Anodynes, for local neuralgia. 
Insomnia. 



r In cerebral . 



Generally . 



Spinal 



and 



Sympathetic 
nerve-cases, in- 
flammatory af- 
fections, &c. . . 



As antidote, diag- 
nostic 

. Anaesthetic . . . . 



Melancholia. 

Mania. 

Delirium tremens. 

Hysteria. 

Chorea. 

Central neuralgia. 

Rheumatism. 

Tetanus. 

Hydrophobia. 

Retention of urine. 

Colic. 

Convulsions. 

Epilepsy. 

Peritonitis. 

Pericarditis. 

Dysentery. 

Ophthalmic surgery. 

Malarial fever. 

Gangrene. 

Dysmenorrhoea. 

Cholera. 

Sea-sickness. 

Cancer. 

Ulcer of stomach. 

Intussusception. 
f For opium, belladon- 
| na, &c. 

f "With or after chloro- 
form or ether in 
operations. 



116 GENERAL THERAPEUTICS. 

The instrument most approved is a small glass syringe, holding about 
half a fluidrachm, and graduated for drops or minims, with a tube for 
puncture, of tempered steel, or of silver with a gold point. The end 
of the tube must be small and sharp. Graduation of the cylinder is 
not necessary, as it is easy to measure the amount to be taken up by 
it. Not much pain is usually produced ; but sometimes it is quite 
severe. If the dose of the medicinal agent be not too large, the only 
danger (unless in an erysipelatous patient) is of a circumscribed 
inflammation. Repeated injections should not be made at exactly the 
same spot. In operating, draw the skin tense with the fore-finger and 
thumb of the left hand, and pass the point of the tube quickly and 
steadily through it. Then push in, not rapidly, the desired amount 
of the fluid. Avoid subcutaneous veins ; the puncture of one of them 
may give an excessive action of the medicine. 

The agents most used are salts of morphia, atropia, strychnia, and 
quinia. For anodyne purposes, Dr. Ruppaner prefers liquor opii 
compositus, of which one hundred drops are equal to a grain of sul- 
phate of morphia. Many use the ordinary solution of morphia (gr. j 
of morph. sulph. in f §j) or Magendie's (gr. ij in f gj). Doses are as 
follows : — 

Sulphate of morphia gr. §• — £ 

Sulphate of atropia gr. ^ — ^ § 

Muriate of strychnia gr. ^\ — J 

Aconitia . . gr. ^ 

Liq. opii compos gtt. v — ix 

Sulphate of quinia gr. i — iv 

Among the diseases in which palliation or relief of suffering is 
often important by means of this method of treatment are especially 
neuralgia, hysteria, cancer and ulcer of the stomach. A case of the 
latter affection is recorded in which for weeks or months the patient 
was only able to retain food upon the stomach after disposition to 
vomit had been allayed by a hypodermic injection of morphia. 

Curative effect from anodynes so employed has been asserted in 
cases of delirium tremens, mania, and tetanus ; from quinine (two to 
four grain doses) in intermittent fever. 

Tentative use of the same mode of practice is justifiable in cholera, 
hydrophobia, poisoning (as the injection of morphia for belladonna 
poisoning, and the converse), violent hooping-cough (atropia), per- 
nicious fever, spotted fever, &c. 

That the operation is always without inconvenience to the patient 
is not true. Not only pain, but local inflammation and even suppu- 
ration may sometimes be induced. But many patients, suffering pain- 
ful complaints, have had a hundred or more injections made in different 
parts of the body, without any disadvantage, and with great relief. 



CONCLUSIONS — MAXIMS. 117 



GENERAL CONCLUSIONS. 



The following may, in recapitulation, be stated to be the most gen- 
eral desiderata in the management of all diseases : — 

Rest ; 

a, in all acute diseases ; 

b, in all cases of exhaustion. 

Balance ; 

a, of ike fluids, and solids; 

b, of the activity of functions. 

Normal blood-change ; 

a, due removal of excretions ; 

b, absence of morbid poisons. 

Support ; 

a, in all asthenic cases ; 

b, in later stages of sthenic cases. 



THERAPEUTIC MAXIMS. 

1. All pathology is but the physiology of organic perturbations. 

2. Never interfere actively in disease without a distinct object. 

3. Act only upon scientific reason, or well-defined experience. 

4. Treat the cause of disease whenever it is possible. 

5. Watch always y and treat, when requisite, the condition of the 
patient. 

6. Avoid, especially, routine treatment according to the names of 
diseases. 

7. Use no violence with self-limited diseases. 

I believe that a sound " theory of medicine" may be expressed in a 
single paragraph, thus : — 

Vital optimism is the aggregate tendency of all the forces of the 
living organism, under the controlling influence of life-force. But, 
the best possible result in a given case may, from its conditions and 
circumstances, fall far short of health. Medicine, then, is to favor 
or supply those conditions which, wider natural laws, allow or pro- 
mote the best result. 

In aiming to fulfil this duty, the art of healing must ahcays depend, 
in part, upon empirical observation (which every branch of know- 
ledge requires) and in part upon inductive science. But in both 
alike, the physician is, or should be, u natural minister et interpres." 



118 NOSOLOGY. 

SECTION IV. 

NOSOLOGY. 

Diseases were by Cullen classified as locales, pyroses, cachexiae, 
and neuroses (local diseases, fevers, cachectic diseases, and nervous 
affections). 

The advances made in pathology since Cullen's time require some 
modification of this arrangement, while retaining its principle. I 
propose, therefore, that diseases be subdivided as — 

Phlegmasia : inflammations. 
Zymoses : zymotic diseases. 
Cachexiae : cachectic affections. 
Neuroses : Nervous disorders. 
Ataxiae : unclassifiable diseases. 

The following list is intended to present only the most important 
diseases of each class. 



Phlegmasiae : 




Laryngitis ; 


Gastritis ; 


Tracheitis ; 


Enteritis ; 


Bronchitis ; 


Dysentery ; 


Pneumonia ; 


Peritonitis ; 


Pleurisy ; 


Hepatitis ; 


Endocarditis ; 


Nephritis ; 


Pericarditis ; 


Meningitis ; 


Stomatitis ; 


Cerebritis ; 


Pharyngitis ; 


Myelitis. 


Zymoses (diseases produced by a 


morbid poison) : — 


Not usually included as zymotic 


, diseases — 


1. Primary syphilis ; 


3. Hydrophobia. 


2. Gonorrhoea; 




Eruptive — contagious — 




1. Yariola; 


4. Varicella ; 


2. Varioloid; 


5. Scarlatina; 


3. Vaccinia ; 


6. Rubeola. 


Contagious — not eruptive — 




1. Parotitis contagiosa (mumps); 


2. Pertussis. 




Generally epidemic or endemic- 




1. Typhoid fever ; 


6. Plague; 


2. Typhus; 


7. Cholera; 


3. Spotted fever ; 


8. Epidemic dysentery ; 


4. Puerperal fever ; 


9. Influenza; 


5. Erysipelas ; 


10. Diphtheria. 



NOSOLOGY. 119 

Endemic — 

1. Yellow fever ; 2. Dengue. 

" Malarial ;" endemic — 

3, Intermittent; Pernicious fever. 

Kemittent ; 

Cachexiae : 

1. Diatheses (general cachexia?) : 
Always chronic — 

a. Spanaemia (anaemia) ; 

b. Chlorosis ; 

c. Leucocythaemia ; 

d. Melanaemia ; 

e. General dropsy; 

/. Hemorrhagic diathesis ; 

g. Tuberculosis ; 

h. Diabetes ; 

i. Lithiasis ; 

j. Secondary syphilis. 

Acute or subacute — 

a. Scurvy ; 

b. Gout ; 

c. Rheumatism ; 

d. Ichoraemia (pyaemia). 

2. Local cachexia? (degenerations) : 

Cancer; 

Various tumors, cysts, etc. ; 

Goitre ; 

Cirrhosis (of the liver) ; 

Bright's disease (of the kidney) ; 

Addison's disease (of the supra-renal capsules, etc.) ; 

Other organic degenerations. 

Skin diseases ; viz. — 

Exanthemata (erythema, urticaria, roseola) ; 

Papulae (lichen, etc.); 

Yesiculae (eczema, etc.) ; 

Bullae (pemphigus, etc.) ; 

Pustulae (impetigo, etc.) ; 

Squamae (psoriasis, etc.); 

Maculae (fuscedo, etc.) ; 

Hypertrophiae (elephantiasis, etc.) ; 

Tubercula (molluscum, etc.) ; 

Haemorrhagiae (purpura) ; 

Neuroses ; 

Parasitica? (scabies, etc.); 

Syphilida. 



120 



NOSOLOGY. 



Neuroses: 

Apoplexy ; 
Paralysis ; 
Epilepsy; 
Catalepsy; 
Hysteria ; 
Chorea; 
Tetanus ; 
Asthma ; 
Angina Pectoris ; 

Ataxias (unclassifiable diseases) : 
Hemorrhages ; 

Local dropsies (ascites, etc.) ; 
Jaundice ; 
Dyspepsia ; 



Laryngismus stridulus ; 
Convulsions ; 
Neuralgia ; 
Delirium tremens ; 
Insanity ; viz. — 

M ania ; 

Monomania; 

Melancholia ; 

Dementia. 



Cholera morbus ; 
Colic ; 
Diarrhoea ; 
Worms. 



PART II. 

SPECIAL PATHOLOGY AM) PRACTICE OF 
MEDICINE. 1 



Hating endeavored, in our previous pages, to state, with brevity, 
the essential principles of the science of medicine, we proceed to 
apply these, in the same condensed manner, to an account of the dis- 
eases to be dealt with in practice. With the view of simplifying to 
the utmost our review of the subject for the use of the student (who 
will find in larger treatises the full discussion of all mooted points), 
but little reference will be made to authorities, and but slight mention 
of varieties of opinion. Our purpose will be, to give a brief and clear 
description of each disease, with its causation, diagnosis, and treat- 
ment, according to the light of experience and authority. 

The classification of diseases followed in the succeeding pages is 
chiefly clinical ; though based upon the pathological nosology already 
stated (Part I. Sect. IV.)- Such an arrangement finds sufficient jus- 
tification in its convenience. 



AFFECTIONS OF THE RESPIRATORY ORGANS. 
PNEUMONIA. 

Definition. — Inflammation of the substance of the lung. 

Varieties. — According to its seat; — single, double, lobular. Ac- 
cording to causation ; idiopathic, from cold and wet; traumatic, from 
injury ; tuberculous, in phthisis ; and typhoid pneumonia. Except in 
phthisis, we scarcely meet with chronic pneumonia ; what is commonly 
called so being induration following acute pneumonia as an effect, not 
a continuation of it. 

Symptoms and Course. — A chill or stage of depression, followed 
soon by fever, with oppression in breathing, dull pain (not always 
present) in the chest, and sometimes short cough. Delirium is com- 
mon. Temperature of the body high, especially on the 4th or 5th 
day; sometimes in the evening, reaching 104 c or lOS^Fahr. in the 
axilla. Secretions scant, as in other febrile states. Urine containing 
an excess of urea, but deficient especially in the chlorides, in the 

1 Note to Part II. — The letter F., followed by a number, in parenthesis, in- 
dicates a reference to a formula, of that number, in the latter part of the book. 
11 



122 DISEASES OF ORGANS OF RESPIRATION. 

middle period of the attack. Expectoration commences about the 
third day usually, the sputa being composed of mucus, lymph, and 
blood mixed together, making the rusty sputum of pneumonia. In 
this an excess of chloride of sodium will be found by testing with 
nitrate of silver. 

The height of the attack is generally reached between the 5th and 
the 7th day ; after which the temperature declines, and, in favorable 
cases, all the symptoms subside. In others, oppression in breathing, 
and prostration increase ; cough deepens, and expectoration becomes 
more abundant, at last purulent. Death seldom occurs before the 
sixth, and may be as late as the twentieth day. 

Stages. — 1st, that of congestion or engorgement, and the commence- 
ment of exudation ; 2d, that of exudation and red hepatization ; 3d, 
that of gray hepatization, softening, or purulent infiltration. 

Physical Signs. — These differ in the three stages. In the first, 
they are, moderate dulness of resonance on percussion over the af- 
fected lung, and, on auscultation, after the first day or two, the fine 
crepitant rale. 

In the second stage, decided dulness on percussion, no rale, but, 
instead, bronchial respiration and bronchophony ; with increased vocal 
fremitus. In the stage of softening or suppurative infiltration (gray 
hepatization), dulness on percussion, and coarse crepitant or mucous 
rale. 

When resolution follows the second stage, as in most cases of re- 
covery, the bronchial respiration gives way to returning fine crepita- 
tion (crepitus redux) ; and, then, the dulness of resonance on percus- 
sion also gradually disappears. 

Terminations. — Kesolution ; death in the second stage from 
asphyxia ; death from exhaustion in the third stage ; recovery after 
the third stage (uncommon) ; abscess; gangrene of the lung. 

Complications.— Pleurisy (pleuro-pneumonia); capillary bronchitis ; 
tubercle. 

Sequelae. — The most frequent is that persistent consolidation of 
the lung called by some chronic pneumonia. Tubercular deposit, 
sometimes even acute phthisis, may follow pneumonia, in persons pre- 
disposed to it. 

Morbid Anatomy. — The lower or middle lobe is almost always tKe 
seat of the disease. Should death take place (as it rarely does) in 
the first stage, the lung would be found somewhat swollen, dark red, 
inelastic (splenization), and filled with blood or bloody serum. It 
will still float in wa^er,. though heavier than healthy lung. It is easily 
torn. 

In the second stage, of hepatization, the lung is no longer spongy, 
but presents considerable resemblance to the liver; although a finger 
may be easily thrust through it. When entirely hepatized, it will not 
float in water, the air being displaced from the cells by the exudation 
of coagulable lymph. 

The third stage consists in the degeneration (in the absence of more 
favorable resolution by absorption) of the exudation. This occurs 
by granulation, softening, and suppuration. Mostly the* latter is 
infiltrated ; occasionally an abscess forms. In gray hepatization, the 
lung is solid, impermeable to air, with a granite-like appearance of 



PNEUMONIA. 123 

red and white points on section. It sinks in water, but is more easily 
torn, or crushed into a pulp, than in the second stage. 

Diagnosis. — The only affections with which pneumonia is likely to 
be confounded are pleurisy, bronchitis, and phthisis. In children, 
collapse of the lung has been mistaken for lobular pneumonia. 

From pleurisy, it is known by the absence of the sharp pain belong- 
ing to the latter, and by the crepitant rale and rusty sputa. From 
bronchitis, by the dulness on percussion, rale, bronchial respiration, 
and bronchophony. From phthisis, by its sudden onset, tine crepita- 
tion, and sputa, as well as by the acute violence of the attack. Latent 
pneumonia sometimes complicates fevers, etc. 

Prognosis. — Simple pneumonia, of one lung, in a young and pre- 
viously healthy person, ought, under favorable circumstances and 
judicious treatment, always to be recovered from. In the aged, it is 
dangerous; and double pneumonia is so at all periods of life, though 
good recoveries do occur. It is double in about one case in eight. 

Among the unfavorable signs — most of which are obvious — are 
expectoration of pure blood in the first stage, and albuminuria in the 
second. 

Pathology and Nature. — Ordinary pneumonia is a phlegmasia, 
with the usual elements of general pyrexia or fever, local hyperemia, 
and local exudation. £ As in other phlegmasia?, the relation of these to 
each other is not easily determinable. Is the local affection always 
the first thing, causing the fever, or is there a blood disease first, pro- 
ducing both the fever and the local affection? In traumatic and 
tuberculous pneumonia, it is plainly the former. In other cases, after 
exposure to cold and wet, we may suppose it to be both ; but the pri- 
mary step of the actual inflammation is probably the local disturbance 
in circulation, functional action, and nutrition. 

Causation. — As already intimated, cold, suddenly or partially 
applied to the body, especially to the chest, is the most common cause 
of pneumonia. But the previous state of the health, and especially, 
also, latent tubercle, may predispose to it. So, in certain regions, 
does the influence of malaria. 

Treatment- — This remains to be a quest io vexata. Having con- 
sidered already (General Therapeutics, p. 85), the principles involved. 
my conclusions may be briefly stated. I am convinced by experience 
that prompt and moderate antiphlogistic treatment may greatly lessen 
the danger of pneumonia, if not shorten its duration. 

Probably five cases in six would recover without the abstraction of 
blood ; the sixth might die for want of it. I believe that the mortality 
of pneumonia has increased in Philadelphia since blood-letting has 
been so generally abandoned. 1 But bleeding from the arm, if resorted 
to, should be done but once ; not later than the third or fourth day ; 
and it may be moderate in amount. Old persons and those of feeble 
system will neither bear nor require it. 

Cupping between the shoulders may, in many cases, take the place 

1 Having no recollection or record in ray notes of private or hospital practice, 
of ever having lost a case of uncomplicated pneumonia, the above language 
expresses my very strong convictions. 



124 DISEASES OF ORGANS OF RESPIRATION. 

of venesection ; in some, it may follow this. The early administration 
of a vigorous purgative, as Epsom salts, or citrate of magnesia, is 
proper, in the absence of any special contraindication. 

Tartar emetic [F. 1] l in the dose of one-eighth to one-quarter of a 
grain for an adult, every two or three hours, may be continued during 
the height of the febrile stage. For this, as for bleeding, the indica- 
tions are to be found not in the physical signs of pneumonia, but in 
the general condition of the system ; not in the crepitant rale, but in 
the hot skin, hard or else oppressed pulse, pain and dyspnoea, and 
more or less darkly flushed face. After the height of the attack, 
small doses of ipecacuanha [F. 5] may be substituted for the anti- 
monial ; or nitrate of potassa [F. 4] , gr. x, every two hours. 

Asthenic pneumonia requires a different treatment ; and the same 
will apply to the third or suppurative stage of all cases. Support 
may be required, in a few cases, even from the first ; by beef-tea, wine, 
or spirits (best with nourishment, as in punch), quinine [F. 2] or 
ammonia [F. 3] . In hospital, I have known more than one case to 
recover under this plan alone; but they are the exceptions. Some 
cases in which bleeding or cupping will be proper in the first stage, 
before the fourth day, may require beef-tea in the second stage, and 
quinine later. A large blister over the affected part is generally useful 
about the fifth, sixth, or seventh day of the attack. 

Varieties of Pneumonia. — When complicated with pleurisy or 
bronchitis, no important modification of treatment is called for. Tuber- 
culous pneumonia requires careful husbanding of the resources of the 
economy. Loss of blood is there rarely proper ; if at all, it must be local 
only, and in minimum quantity. The necessity for the analeptic treat- 
ment of the tuberculous condition is paramount. Dry cups, blisters, 
and counter-irritant plasters, or croton oil or tartar emetic ointment 
externally applied, are then suitable. Warm poultices, as of Indian 
or flaxseed meal, with or without the addition of mustard, kept on 
day and night for a time, are often very useful, especially in children. 

Traumatic pneumonia, following an injury, is not common. It 
calls for no particular difference of treatment. 

Typhoid pneumonia is a term not always uniformly applied. It 
means, sometimes, or with some authors, inflammation of the lungs 
complicating typhoid fever ; others include under it all cases of asthe- 
nic pneumonia. More generally, however, it designates that form of 
the disease in which epidemic or endemic influence has impressed a 
peculiar character. Malarial regions especially exhibit this, in the 
" winter fever" or typhoid pneumonia of our southern states. Early 
and great debility, out of proportion to the local symptoms, with a 
tendency to low delirium, and to remittance, mark this disorder. In 
treatment, it bears little or no depletion, hardly the reduction of ex- 
citement by tartar emetic or veratrum viride. Diaphoretics first, as 
[F. 6] ipecac, ^ a grain, with the same amount of calomel and five or 
ten grains of nitrate of potassa, every three hoars; or liquor ammo- 
niaB acetatis [F. 7], or solution of acetate of potassa [F. 8] ; then 
quinine, when the need of a tonic is apparent, which may be very 

1 F., with a number, in parenthesis, refers to a formula in the collection at 
the end of the book. 



PLEURISY. 125 

early; with strong liquid nourishment, and moderate counter-irrita- 
tion ; these are the measures usually proper in typhoid pneumonia. 

After recovery from an attack of inflammation, the lung will be 
for some time more than usually susceptible to conditional changes. 
Exposure should, then, be carefully avoided ; and flannel may be worn 
next the skin. In winter a mild warming plaster, as of hemlock or 
Burgundy pitch, over the chest, will give good protection. 

PLEURISY. 

Definition. — Inflammation of the pleura. 

Varieties. — Single or unilateral, and bilateral or double ; idiopathic, 
traumatic, and secondary, e. g., tuberculous, cancerous. Chronic pleu- 
risy, so called, is merely the consequence of an acute attack. 

Symptoms and course. — Generally, after a chill or cold stage, 
sharp pain in the side, impeded and accelerated respiration, short, 
sharp cough, and fever. The pain centres in the infra-mammary or 
lower axillary region ; it is often intense, and is increased by a long 
breath, by coughing, pressure, or lying on the affected side. The pain 
and fever lessen after effusion has occurred ; but the dyspnoea may 
then be increased. It is, after that period, most comfortable to lie on 
the diseased side, so as to allow of free breathing by the other lung. 
Acute pleurisy is often recovered from without any considerable effu- 
sion. When the latter does occur, absorption mostly follows. If 
not, life is endangered by interference with respiration. At first 
serous, constituting one form of hydrothorax, the fluid may become 
purulent; this is empyema. The term false empyema is sometimes 
given to a collection of pus in the pleural cavity from the rupture of 
an abscess in the lung. Pneumothorax is the accumulation of air in 
the cavity of the pleura ; hydro-pneumothorax, of water and air 
together. Both of these are most common in tuberculous pleurisy, 
». e. in the course of a case of pulmonary phthisis. 

Stages. — In severe pleuritis there may be, 1, the adhesive ; 2, the 
effusive ; 3, the suppurative stage. In t&ore favorable cases the 3d 
stage is that of absorption. 

Physical signs. — Of the 1st stage, deficient elevation of the ribs 
in breathing, feeble respiratory murmur on the affected side, and 
friction sound. 2d stage, dulness of resonance on percussion, bron- 
chial respiration, bronchophony, sometimes wgophony. When the 
effusion becomes very copious, bulging of the side occurs, suppression 
of respiratory sound and of vocal resonance and vibration, with ex- 
aggerated or puerile respiration on the sound side. Displacement of 
the heart may take place if it is on the left side ; of the liver if on the 
right. There is no physical sign by which empyema can be distin- 
guished from serous effusion; but irritative fever usually accompanies 
empyema. 

Absorption following extensive effusion allows retraction and de- 
pression of the chest on that side, from the slow or imperfect expansion 
of the lung. Then return, first, bronchial respiration and voice, or 
asgophony, then gradually the normal respiratory murmur. Some- 
times, from adhesions of false membrane over the lung, permanent 
depression of the thorax on that side is left. 

11* 



126 DISEASES OF ORGANS OF RESPIRATION. 

During effusion, its fluid character as well as extent may be shown by- 
percussion in different positions. Sitting up, it falls forward, and rises 
to a higher line in front ; lying on the back, the dulness, from gravitation, 
may fall much lower in the anterior region. Sometimes adhesions pre- 
vent this. Succussion, or sudden shaking of the chest of the patient, may 
produce an audible splashing, if the ear be upon or near the affected 
side. By ocular inspection and measurement, the changes in the 
amount of the effusion may be estimated from time to time. 

Terminations. — Pleurisy may sometimes be " nipped in the bud" 
at an early stage by appropriate treatment; that is, prompt resolution 
of the incipient inflammation may be effected. The other terminations 
are, serous effusion, which may vary from an ounce or two to quarts, 
gradually absorbed altogether ; the same, slowly and incompletely 
absorbed, leaving collapsed lung; death, in double pleurisy, by 
asphyxia from excess of fluid ; and empyema, often, but not always 
fatal by slow exhaustion. 

Complications. — Pneumonia, tubercular deposit, inflammation of 
the liver (bilious pleurisy). 

Sequelae. — What authors call chronic 'pleurisy is the sequela of 
acute pleuritis. Its results and terminations have been above named. 

Morbid Anatomy. — In the early period, general redness and 
vascular injection of the pleura, with bands of whitish and more or less 
translucent or opaque coagulable lymph, causing adhesions of the 
pulmonary and costal pleura. Later, serous, sanguinolent or purulent 
effusion, in variable quantity, and sometimes displacement of the heart, 
lungs, and liver, and bulging of the ribs and intercostal spaces. 

Diagnosis. — From pneumonia, pleurisy is known in the height of 
the acute attack by the sharpness of the pain, the friction sound, and 
absence of crepitant rale and of dulness on percussion. After effusion, 
especially by the change of the line of dulness with change of position, 
sitting and recumbent ; by the bulging ; and the degree of diminution 
of vibration of the walls of the chest when speaking. 

From intercostal neuralgia, pleurisy is distinguished by the absence 
of fever and friction sounds in the former, and the non-increase of the 
neuralgic pain upon inspiration. Congestion, in some rare cases, 
attends neuralgia ; the diagnosis is then more difficult. In intercostal 
muscular-rheumatism, there is slight increase of pain in breathing 
deeply, but as much in moving the arms ; and the pain is much less 
acute, and generally without fever. 

Prognosis. — Pleurisy is rarely fatal ; though death may occur, from 
very abundant effusion in bilateral pleuritis, or, with empyema in the 
unilateral, through gradual exhaustion. 

Causation. — Exposure to cold and damp is the ordinary exciting 
cause of " idiopathic" pleurisy. Fracture of the rib, punctured wounds, 
&c, may cause traumatic pleurisy. In the course of phthisis, it not 
uncommonly occurs by extension of the disease from the lung. Cancer 
of the chest may produce it in an analogous manner. 

Treatment. — In young and vigorous persons, still more confidence 
may be placed in early antiphlogistic treatment than in pneumonia. 
When high fever and constant severe pain occur, bleeding, in such 
patients, on the first, second, or third day, should be the general rule. 
Leeches or cups may follow, or be used instead of venesection in 



ABSCESS OF THE LUNG. 12t 

doubtful cases. Tartar emetic, after a free purge, may be given, ^ to 
\ of a grain every two or three hours, with ^ to 1 grain of opium. 
Many practitioners add calomel, J grain to 1 or 2 grains every two 
or three hours [F. 9.] When fever subsides, or vomiting occurs, the 
antimony should be withdrawn ; the opium and calomel may be con- 
tinued, while the pain lasts, — carefully avoiding over-narcotism by the 
former, and salivation by the latter. 

As soon as the heat of skin has considerably abated, if the pain 
continues, a large blister should be applied over the affected part. 

For the effusion, diuretics, as squill [F. 10] , juniper berry infusion, 
or compound spirit [F. 11], acetate or bitartrate of potassa [F. 12], 
etc., may be used. Iodine, in Lugol's solution, and iodide of potassium 
alone, are often advised. Repeated blistering sometimes has excel- 
lent effect. 

When life seems to be threatened by exhaustion from dyspnoea, 
owing to large effusion not becoming absorbed, paracentesis, or punc- 
ture of the chest, is proper. Dr. Bowditch's plan is the best for this. 
He uses Dr. Wyman's apparatus, which is a trocar, with a silver 
canula having a stopcock, and capable of being connected with a 
syringe by an intermediate piece, also having a stopcock, both cocks 
acting the same way. The operation is performed while the patient 
is sitting up, if able, or lying over the edge of the bed. The puncture 
is made somewhere between the seventh and tenth ribs, just behind 
their angles ; making sure first of the position of the liver and spleen, 
so as to avoid them. Insert the instrument near the upper edge of 
the lower rib, raising its point as it goes in. When the trocar is 
withdrawn, by the double-cocked syringe the fluid may be gradually 
removed with safety to the slowly expanding lung. The operation 
may need to be repeated, even several times in the same patient. 

The grooved needle or exploring trocar is often used to ascertain 
the nature of the contents of the chest. When pus is present (em- 
pyema) in considerable amount, "drainage" may be resorted to. 
Following the grooved needle or trocar, a fine long iron probe, some- 
what bent, is passed through to the lower and back part of the pleural 
cavity, against the intercostal space. Being felt there, an incision is 
made upon it ; a strong silk thread is passed through its eye, and then 
drawn through the first opening. After this, draw in a drainage 
tube, of India rubber perforated with many holes ; both of whose ends 
hang out and are tied together. Sometimes, by the tube, the cavity 
may be ivashed out, with water, or dilute astringent or antiseptic 
solutions. 

In chronic cases of pleuritic effusion or empyema, the strength of 
the patient requires usually to be supported by good diet, and some- 
times by tonics. This, in empyema, is often the most important part 
of the treatment. 

ABSCESS OF THE LUNG. 

In rare instances, inflammation of the lung, active or latent, may 
terminate in abscess. Before rupture, dulness on percussion, bronchial 
respiration, and dyspnoea proportioned to the size of the abscess, are 
present. When an opening occurs allowing the matter to escape into 



/I 



128 DISEASES OF ORGANS OF RESPIRATION. 

the bronchial tubes, the rather sudden commencement of purulent 
expectoration should attract attention. Then the physical signs of a 
cavity are discoverable by percussion and auscultation ; amphoric or 
tympanitic resonance on percussion, cavernous respiration, metallic 
tinkling, etc., varying with circumstances. As is the case with pleu- 
ritic empyema, pulmonary abscess may communicate externally by a 
spontaneous opening. 

The principal importance of abscess of the lung consists in the possi- 
bility of mistaking it for phthisis. The points of difference will be 
alluded to in connection with that disease. 

PULMONARY GANGRENE. 

This may occur in pneumonia from extreme violence of the inflam- 
mation, or from a depressed state of the system; also, from cancer 
within the chest, pyaemia, etc. It is rare, but more common than 
circumscribed abscess of the lung. Unless very narrowly limited, 
pulmonary gangrene is always fatal. Its signs are, coarse mucous 
rale, taking the place of the vesicular murmur in the lower part of the 
lung, with copious brownish and offensively fetid expectoration, 
dyspnoea, and great prostration. 

In bronchitis, occasionally, temporary fetor of the expectoration 
and breath may simulate gangrene ; but transiently, and without the 
above symptoms. 

The treatment of pulmonary gangrene must be, of course, support- 
ing and antiseptic. Alcoholic stimulants, rather freely given, will be 
proper, with concentrated liquid food, as beef-tea. Sulphite of soda 
(ten grains in solution every three hours) may be tried ; or chlorine 
water, a teaspoonful or two every two or three hours. 

EMPHYSEMA OF THE LUNG. 

This is dilatation of the pulmonary air-cells of one or both lungs. 
It may accompany prolonged asthma, or may follow chronic bron- 
chitis. Sometimes it aids in producing dilatation of the heart. Its 
symptoms are, dyspnoea, and, when extensive, blueness of the lips, 
cyanosis, from interference with the circulation through the lungs ; in 
many cases wheezing respiration. The physical signs are, bulging of 
the chest, increased clearness of resonance on percussion, and feeble 
inspiratory murmur with prolonged expiratory sound ; sometimes dis- 
placement of the heart or liver. It is most easily mistaken for 
pneumothorax. But, in the latter, the resonance on percussion is 
more tympanitic, the inspiratory murmur still feebler, or quite absent, 
and there is no prolonged expiratory sound ; besides which, the con- 
comitants of pneumothorax usually serve to distinguish it. 

COLLAPSE OF THE LUNG. 

In hooping-cough or in severe bronchitis, especially in children, ob- 
struction of a considerable air-tube may lead to an exhaustion of air 
from the cells supplied by it, and a return of that portion of the lung 
to the unexpanded condition (atelectasis) of foetal life. The same 



BRONCHITIS. 129 

state may occur in other conditions, from debility. It was formerly 
always mistaken for lobular pneumonia. It is usually fatal, unless 
very much limited. 

Signs of it (often difficult of determination, however) are, moderate 
dulness on percussion, with absence of the murmur of respiration ; 
and, in some cases, an inward motion or recession of the lower ribs 
during the effort at inspiration. 

BRONCHITIS. 

Definition. — Inflammation of the mucous membrane of the bron- 
chial tubes. 

Varieties. — Acute and chronic ; general, capillary ; plastic, rheu- 
matic and syphilitic bronchitis. 

Symptoms and course. — Systemic depression, followed by fever ; 
tightness and soreness of the upper and anterior part of the chest ; 
cough, at first short, dry and tight, later deeper and looser, with ex- 
pectoration ; the latter being at first mucous, in rare instances pseu- 
do-membranous, in severe cases at a late stage purulent. 

Capillary bronchitis is marked by greater dyspnoea and tendency to 
early depression and prostration. 

Chronic bronchitis often is free from febrile symptoms, the cough 
and expectoration, with slight dyspnoea, characterizing it. 

Stages. — Ordinary bronchitis may be divided in its progress into 
1st, the stage of diminution of secretion ; and 2d, that of increase and 
'perversion of it. 

Physical signs. — No dulness on percussion, except in case of col- 
lapse of part of a lung from obstruction ; sonorous rhonchus and sibilus, 
generally, though not quite always, on both sides of the chest ; vary- 
ing from time to time, in seat, character, and loudness. In capillary 
bronchitis, extended mucous, crepitant or subcrepitant rales, closely 
resembling the fine crepitation of pneumonia. 

Terminations. — Acute bronchitis may end in death from apnoea, 
in the first or second stage ; or in chronic bronchitis ; but most gene- 
rally in recovery. 

Complications. — Asthma ; pneumonia ; bronchial dilatation ; pul- 
monary collapse. 

Morbid anatomy. — General redness and congestive tumefaction of 
the bronchial membrane ; with more or less obstruction from mucus, 
epithelium, and, rarely, casts of the tubes, of plastic lymph. 

Diagnosis. — No difficulty exists except in distinguishing chronic 
bronchitis from phthisis. Absence of dulness on percussion and of 
the signs of excavation, are most important; the expectoration also 
is whiter and of less weight in bronchitis ; and there is no hectic fever. 

Prognosis. — Acute bronchitis is dangerous in old persons and young 
children ; seldom fatal in vigorous middle life. The capillary form is 
always most serious ; death taking place sometimes from the 10th to 
the 12th day. Chronic bronchitis is not often fatal, even by ex- 
haustion ; but it may last an indefinite time, even many months. 

Causation. — Exposure to cold is the most frequent cause. In 
some employments, as needle-grinding, cotton-spinning, &c, solid par- 
ticles inhaled cause bronchitis by mechanical irritation. Transference 



130 DISEASES OP ORGANS OF RESPIRATION. 

of rheumatism occasionally induces it in the rheumatic diathesis ; and 
occasionally it is one of the manifestations of tertiary syphilis. 

Treatment. — Abortive treatment of a "cold on the chest" may 
sometimes be effected within the first twenty- four hours, by taking, at 
bedtime, a glass of hot lemonade or ten grains of Dover's powder 
after a warm mustard foot-bath. Should this fail or be omitted, a 
brisk saline purgative should be given, of Epsom or Rochelle salts, 
or citrate of magnesia. Then, when the fever is high, cough very 
tight, and breast sore, tartar emetic should be advised, ^ to ^ grain 
every two or three hours, [F. 1] with frequent draughts of flaxseed 
tea or some similar demulcent. A large sinapism over the upper 
sternal region will aid in giving relief; and so will friction with oil of 
turpentine. 

In milder cases, or where the strength of the stomach is doubtful, 
syrup of ipecacuanha, {- to £ drachm every two or three hours, will 
answer ; and should be continued until the cough softens and the breath- 
ing becomes easier. Then syrup of squills [or, F. 13] may follow, in f. 
drachm doses, every three or four hours. When the cough is trouble- 
some at night, ^ to 1 f. drachm of paregoric [F. 15] may be added at 
bedtime ; or through the day, occasionally, if coughing be very violent 
or frequent. Opiates do the most good, however, after some loosening 
of the cough with free expectoration. When the fever has abated, 
and especially if dyspnoea continue, a blister may be applied over the 
sternum. 

In capillary bronchitis, or in the ordinary form in the aged and feeble, 
instead of tartar emetic the more stimulating expectorants may be re- 
quired, as senega, in decoction or syrup, muriate [F. 15] or carbonate 
of ammonia, with quinine and beef-tea, wine-whey, or brandy-punch. 
Inhalation of steam, alone, or from infusion of hops, sometimes soothes 
the air-tubes advantageously. (See Inhalation and Atomization, in 
Part I., Sec. III.) 

Chronic bronchitis requires persevering use of counter-irritation 
over the chest, by croton oil (3 drops with the same of sweet oil ap- 
plied nightly till a papular eruption follows), painting with tincture of 
iodine, or plasters of Burgundy pitch, hemlock, &c, and alternation 
of stimulating and alterative expectorants, and tonics. Besides squill 
and senega, ammoniacum, copaiba [F. 17], and muriate of ammonia 
[F. 16] are most frequently useful. If the system be below par, qui- 
nine, iron, and cod-liver oil are important. When secretion is very 
copious, inhalation of tar-vapor or of creasote should be tried. The 
former may be used by putting an ounce or two of tar in a cup over 
boiling water ; so as to diffuse the tar-vapor through the chamber. 
Creasote, 20 or 30 drops, may be put into half a pint of boiling water, 
to be breathed by means of an ordinary inhaler. When medicine fails, 
change of air will sometimes entirely cure. 

ASTHMA. 

Definition. — Paroxysmal and spasmodic dyspnoea. 

Varieties. — Idiopathic and symptomatic; dyspeptic asthma; hay 
asthma. 

Symptoms and Course. — Every night, or once a week, month, or 
year, or at irregular intervals, the attack comes on. Most frequently 



ASTHMA. 131 

it is between 1 and 3 o'clock in the morning. Premonitory symptoms 
often are great drowsiness, or wakefulness, headache, flatulence, itch- 
ing under the chin. Dyspnoea is then the characteristic symptom. 
The sufferer sits or stands up, leaning forward, and labors to breathe. 
The chest is expanded to its utmost, by the accessory as well as prin- 
cipal inspiratory muscles. The countenance is anxious, with pallor, 
coldness, and in severe cases lividness, of the face and hands. Per- 
spiration is often copious. A wheezing sound accompanies respira- 
tion; giving way finally, with relief, upon the expectoration of mucus, 
usually rather thick, and in pellets. 

The attack may pass over in a few minutes, or may last for hours, 
or, with some remission, days or weeks. Where asthmatic symptoms 
are persistent, as is not very uncommon, for years, some structural 
change in the organs of the chest exists; it is then symptomatic 
asthma. 

Physical Signs. — Inspection shows unusual elevation of the ribs 
and shoulders. Placing the ear on the chest, sonorous and sibilant 
Sounds, loud but mostly small in calibre, are found to take the place 
of the respiratory murmur. These sounds change their locality fre- 
quently. As the attack gives way, with expectoration, some mucous 
rale is heard. 

Secretions. — At the beginning of the paroxysm, the urine is abun- 
dant and pellucid (" nervous urine"') ; for some hours after it has 
ceased, it is more scanty, and is deficient in urea and chloride of 
sodium. 

Complications. — Bronchitis; pulmonary emphysema; dilatation or 
hypertrophy of the heart. 

Diagnosis. — Laryngeal spasm may. without care, be confounded 
with asthma; but the modification or arrest of the voice ought to dis- 
tinguish the former. Violent bronchitis is known from it by the febrile 
condition. Angina pectoris, by the extreme pain, and localization 
of the distress about the heart. Hydrothorax. by the dulness of reso- 
nance on percussion, and absence of rhonchus. 

Special exploration is necessary in each case to determine the 
presence or absence of pulmonary or cardiac complication. 

Prognosis. — Death almost never occurs during the fit of asthma. 
Those subject to it often live to old age. But dilatation of the pulmo- 
nary air-cells, and enlargement of the heart, may follow in protracted 
cases, breaking down the health. 

Pathology and Nature. — It has been made certain that asthmatic 
dyspnoea is owing to a spasmodic constriction of the smaller bronchial 
tubes, by tonic contraction, mostly reflex, of their involuntary muscu- 
lar fibres. 

Causation. — Asthma is hereditary in a majority of cases. Males 
have it more often than females. It may occur at any age. Dr. 
Salter classifies cases according to their causation — 1. by agencies 
acting upon the lungs, as fog, smoke, fumes of various things, as ipe- 
cacuanha, mustard, new hay, &c. ; 2. by reflex action, as irritation of 
the stomach from indigestion, loaded rectum, sudden emotion; 3. by 
pulmonary or cardiac disease. Behind all these there must be a pre- 
disposing peculiarity of constitution. 



132 DISEASES OF ORGANS OF RESPIRATION. 

Treatment. — During the attack, our aim must be to give relief, by 
relaxing spasm. Ipecacuanha wine, with tincture of lobelia, one- 
quarter to one-half fluidrachm of each [F. 18], every half hour until 
nausea or expectoration is produced, I have known often to act very 
well. Hoffmann's anodyne, in one-half drachm or drachm doses, will 
sometimes do great good. Some practitioners advise hyoscyamus, 
musk [F. 19], and hydrocyanic acid [F. 20]. Smoking tobacco is 
relieving in some instances ; smoking cigarettes of stramonium leaves 
in others. More still find comfort in breathing the air in which are 
burned papers which have been soaked in a saturated solution of 
nitrate of potassa. Inhalation of ether or nitrous oxide may be care- 
fully used in extreme cases. As an adjuvant, the warm mustard foot- 
bath may be employed ; as well as sinapisms or dry cupping between 
the shoulders. 

Between the attacks, endeavor should be made to rectify digestion 
and its tributary processes, and to invigorate the nervous system. 
Some cases will require blue pill, nitro-muriatic acid [F. 21], or 
taraxacum, bitter tonics and mild laxatives, such as rhubarb, etc. 
Others need iron and quinine. Iodide of potassium is highly recom- 
mended by some ; conium, cannabis indica, and arsenic in small doses 
by others. There is reason for giving trial to the bromide of potas- 
sium in obstinate cases ; most patients will bear from 10 to 20 grains 
of this twice or thrice daily for weeks together without inconvenience 
[F. 22]. 

Prophylaxis. — No disease is more curiously capricious in its 
causation than asthma. Some always have a paroxysm if they visit 
the sea-shore ; others are more secure there than elsewhere. One can- 
not sleep on the first floor; another does better there than higher up. 
Each must learn his own peculiarities, and be governed thereby. 

Most remarkable are the annual attacks of asthma, or asthmatic 
bronchitis, to which a few individuals are subject. I know one gen- 
tleman who for many years was obliged to arrange all his business for 
such an attack, which was punctual almost to a day, in the summer, 
and confined him to his room for a week or two. He escaped the 
paroxysm only by going to the sea-shore before the expected time, 
and remaining there through the time during which it would have 
lasted. 

In asthmatic persons generally, nothing is more important than pru- 
dence and regularity in diet and regimen. 

BRONCHIAL DILATATION. 

This, of which extreme degrees are not common, is of interest 
chiefly because it is possible for it to be mistaken for phthisis. There 
are two forms ; the tubular and the saccular enlargement. 

In either, slight dulness on percussion may occur, from condensation 
of the lung around the expanded part. Sonorous rhonchus and coarse 
mucous rale exist, the latter especially in the saccular form. In this, 
the signs are almost identical with those of tubercular excavation ; 
but they occur usually at the middle or lower part of the lung, and 
are stationary, as they are not in tuberculization. 



LARYNGITIS — APHONIA. 133 

Cough, very troublesome, and attended by copious mucous or 
slightly purulent expectoration, is common in bronchial dilatation. 
The palliation of this symptom, with care of the general condition of 
the patient, is all that can be accomplished for it in treatment. 

LARYNGITIS. 

Slight inflammation or congestion of the mucous membrane of the 
larynx is very common as the result of cold ; its signs being hoarse- 
ness, with a dry, short, harsh cough, and some soreness in drawing a 
breath. But simple acute laryngitis of severe grade is quite a rare 
affection. 

When it occurs, there is fever, with hoarseness, " brassy" cough, 
distressing dyspnoea, and difficulty of swallowing. (Edema glottidis, 
or submucous effusion of serum, constitutes the greatest danger in 
laryngitis ; the swelling obstructing respiration to a degree often fatal. 
This disorder is almost exclusively met with in adults. 

Early purging, the application of leeches, the internal use of ipecac, 
in doses just short of nausea, with moderate quantities of opium, and 
the frequent inhalation of the steam of boiling water, constitute the 
best treatment. If dyspnoea become decidedly serious, threatening 
asphyxia, tracheotomy is advised. Some account of this operation 
will be given in connection with Croup. 

(Edema of the glottis maybe produced immediately by the ingestion 
of boiling water, or of sulphuric or nitric acid, which has often acci- 
dentally happened. 

Chronic laryngitis, with ulceration, is a not infrequent attendant of 
phthisis. Some cases of the latter begin with it ; in others it occurs 
somewhat late in the course of the disease. Syphilitic ulceration of 
the larynx is tolerably common, as a secondary symptom. This, as 
well as polypi or other tumors of the larynx, may be discovered, and 
treated by operation for removal, or with solutions of nitrate of silver, 
&c, with the aid of the laryngoscope. 

My confidence in the utility of very strong solutions of nitrate of 
silver in chronic inflammations of the mucous membranes, of the 
throat or elsewhere, has not increased, in fact has not been sustained, 
by what I have seen in practice. Dr. Horace Green and others make 
frequent use of it of the strength of sixty grains to the ounce. Ex- 
cept for ulceration, which may benefit even by the solid caustic, I 
believe that from four to ten grains in the ounce of water will do more 
good, in almost all cases, than the stronger proportions. 

The application of nebulized liquids, by apparatus for atomization, is 
now much in vogue in both acute and chronic laryngitis. Some remarks 
upon this have been made already, under general therapeutics (Part I.) . 

APHONIA. 

Loss of voice may be transient or permanent; and either functional 
or structural in its origin. Especially in hysterical females, a nervous 
shock may produce a paresis or enfeeblement of the vocal power, 
lasting often for days together. I knew of one case in which a young 
woman could only speak in a whisper for more than three months. A 
12 



134 DISEASES OF ORGANS OF RESPIRATION. 

choreic affection of the vocal apparatus is now and then met with ; 
stammering is, in fact, analogous to this ; depending on a want of 
command and co-ordination of the vocal muscles. 

Faradization, i. e. the use of induced electrical currents (as mag- 
neto-electricity), carefully applied, has sometimes cured nervous or 
hysterical aphonia. I have known vesication of the back of the neck 
to be useful for it. 

Congenital dumbness, except in idiots, is due to deafness, making 
the learning of speech impossible, unless by a recently invented 
system of instruction by sight. 

Organic or structural aphonia is caused by lesions of the larynx, 
such as ulcerative destruction of the vocal cords, tumors, etc., which 
are to be diagnosticated by laryngoscopy. 

Feigned dumbness is detectable by careful watching, or, in the last 
resort, by etherization. In the stage of early excitement, or when 
reviving from anaesthesia, the pretender will betray himself by invol- 
untary speech. 

The term dysphonia clericorum has been applied to an affection of 
the throat not uncommon among clergymen and other public speakers, 
called by Dr. Horace Green "follicular disease of the pharyngo-laryn- 
geal membrane." Its symptoms are soreness and irritation in the 
throat, with disposition to hawk and spit frequently, and hoarseness 
or partial loss of voice. On inspection, the fauces, pharynx, and 
glottis are found to be of a reddish granular appearance, with more or 
less enlargement of the mucous follicles, and, in severe cases, a muco- 
purulent secretion about the uvula. Sometimes, however, the mem- 
brane is dry. 

The conventional treatment for this affection is, the application 
every day or two of a solution of nitrate of silver, with a brush or 
probang. Saturated solution of tannin is also used for it. My belief 
is that, if these local remedies do not relieve in a week or two, the 
frequent swallowing of small pieces of ice, or gentle gargling several 
times a day with ice-water, may be substituted with advantage. 
Counter-irritation over the throat, especially by croton oil, should, if 
necessary, be persevered in for a considerable time. Three drops of 
the oil (diluted with as much sweet oil for a delicate skin) may be 
rubbed over a limited space in front of the throat every night until a 
papular eruption comes out. 1 

Many cases of this complaint are as much constitutional as local in 
origin. Where real dysphonia (difficulty or imperfection of vocaliza- 
tion) exists, public speaking or singing must be avoided, to allow the 
organs repose. Tonics and change of air may often prove the best 
measures of treatment. 

APHASIA. 

Loss of speech may occur as one of the symptoms of disease of the 
brain, either functional and transient, or organic and irremovable. 
Such a loss of language is termed aphasia. Importance has been 

1 Patients should be cautioned, of course, against allowing the oil to come 
near the eyes. I have known a severe ophthalmia to result from neglect of 
this. 



LARYNGISMUS STRIDULUS — CROUP. 135 

given to it lately by the observations of Trousseau and others, and re- 
sulting speculations (Dax, P. Broca) as to the seat of the faculty of 
speech. Not articulation, as in aphonia, but expression is, in this 
affection, wanting. The power to write words from memory, to con- 
vey meaning, is lost ; but, in some cases, at least, they may be copied 
correctly. Thinking without words may go on in such instances ; as 
Lordat recorded, after recovery, in his own case. 

Hemiplegia of the right side has in a number of examples coincided 
with aphasia ; and, several times, also, autopsy has shown softening 
or other lesion of the left anterior portion of the cerebrum. On the 
suggestion of these facts a hypothesis has been based, that the site of 
the faculty of language is in the anterior frontal convolutions of the 
left hemisphere of the cerebrum. This is a very unphysiologieal 
supposition, in view of the symmetry of the cerebro-spinal axis through- 
out ; nor does this objection disappear even upon the conjecture that 
the " organ" upon the right side may exist always in an undeveloped 
state. Valvular lesion of the heart sometimes accompanies the dis- 
ease. 

Cases of aphasia are rare. I have never seen one, 1 and am not 
aware of any special measures of treatment for it pointed out as yet 
by experience. 

LARYNGISMUS STRIDULUS. 

This is an infantile affection, consisting in spasmodic closure of the 
glottis, causing a stridulous or shrill whistling respiration. It is most 
apt to occur during dentition, but is not very common. Its onset is 
sudden, and duration brief. Though exceedingly alarming, it is seldom 
fatal. 

The treatment must be prompt; — producing derivation by slapping 
the back and limbs, and putting the feet into hot water, while cold 
water is applied to the head. In severe cases mustard plasters (di- 
luted with flour) may be applied to the chest and back. Some advise 
the momentary inhalation of chloroform. When life is really in great 
danger from prolongation of the spasm, tracheotomy may be justifiable. 
Children who have laryngismus are generally ansemic ; requiring iron 
[F. 23] and salt baths. 

CROUP. 

We understand by croup, an acute cynanche or angina, whose signs 
are, a hoarse cough, — difficult and audible respiration, and aphonia ; 
the seat of the disorder being the upper portion of the air-passages. 
Its place in nosology has been empirically or conventionally (rather 
than systematically) established. 

For brevity's sake, the following propositions may be advanced : — 

1. The pathological elements of croup are, a, spasm ; b, hyperemia 
or congestion ; c. inflammation, either ordinary or diphtheritic. 

The spasm affects especially the muscles, whose action tends to 

1 An account of an interesting case has recently been sent to me by Dr Sig- 
mund, of Lehigh County, Pennsylvania, in which aphasia, with right hemiplegia, 
followed an apoplectiform seizure (preceded for some months by severe pain in 
the head) ; the patient recovered entirely. 



136 DISEASES OF ORGANS OF RESPIRATION. 

close the rima glottidis; but may involve also the muscular coat of 
the trachea itself. 

The hyperemia commences in the mucous membrane of the larynx 
or trachea, but often extends throughout the whole anterior cervical 
region. 

The inflammation may be located in a small portion of the same 
mucous membrane, or, it may extend downwards indefinitely into the 
bronchial tubes. 

2. We may mentally distinguish between cases in which the croupal 
dyspnoea results from simple spasm, from simple tumefaction, or from 
inflammation without any spasmodic constriction of the glottis. But 
in practice the pathognomonic cough and breathing rarely attend 
such an isolation of one of these conditions. A certain number of 
cases, however, occur, of purely spasmodic or nervous xroup ; now 
and then substituting more general convulsions ; as when worms have 
been apparently an exciting cause. A purely inflammatory case is 
at least equally rare. In fatal pseudo-membranous cases, autopsic 
examination has repeatedly shown that the amount of false membrane 
was by no means sufficient, alone, to have occluded the larynx or 
trachea ; the result being due to the additional spasmodic contraction. 

3. The most frequent form of the disease, common night croup, is 
pathologically characterized by spasm of the glottidean apparatus, 
with congestion and tumefaction (transient in character), of the 
laryngo-tracheal mucous membrane. 

It is in these respects precisely analogous in nature to the asth- 
matic attack, whose seat is in the smaller bronchia?. There is no 
strongly marked line of separation between this form and the catarrhal 
croup, or croupal catarrh, in which more or less active inflammation 
occurs, prolonging the existence of the symptoms. 

4. Looking then, on the hyperaemic state as simply intermediate, we 
may classify the cases of croup, as they ordinarily occur, clinically, 
as, 1st, those in which spasm predominates ; and 2dly, those in which 
inflammation is the dominant condition ; or, bearing in mind the above 
expressed qualification, into spasmodic and inflammatory cases. 

5. Pseudo-membranous, or " true croup," does not generically differ 
from inflammatory croup ; of which it is only a grade or termination : 
t. e. any case of inflammatory or catarrhal croup may end in the exu- 
dation of coagulable lymph within the air tubes. 

6. Whether this shall occur or not, in any given case, depends, a, 
on the degree of the inflammation ; Z>, on the state of the blood of the 
patient ; c, on the treatment. 

7. It cannot be predicated on the ground of experience, that either 
vigorous and plethoric, or feeble and anaemic children, are especially 
prone to the membranous form or termination of inflammatory croup. 
It may and does occur frequently in both. 

8. The ordinarily recognized signs for the diagnosis of inflammatory 
from non-inflammatory croup, are sufficient, viz. the persistent dura- 
tion of the croupal cough and voice — the (generally) slow onset — the 
febrile symptoms — and the stridulous inspiration, as the dyspnoea 
increases. 

9. Inflammatory or true croup is, with the above inclusion (as 
always potentially membranous), not at all necessarily fatal, although 



croup. 13T 

highly dangerous. The presence of the false membrane itself, does 
not inevitably determine a fatal result. 

10. In no disease does more depend on early treatment, which is 
often prevented by the insidious approach of the attack, deluding the 
parents. The mortality of the disease may thus in part be accounted for. 

11. In the treatment of all forms of croup, relaxation and secretion 
are the two great desiderata. 

12. In the spasmodic cases, emetics and antispasmodics (e. g. ipe- 
cacuanha, onion, assafoetida. or lobelia) will effect these objects, 
especially if aided by the warm bath or foot bath. 

13. In mild inflammatory cases, saline purging, gentle vomiting, and 
the use of demulcents, counter-irritation, and pediluvia will relieve. 

14. In the more active cases, the loss of blood by the lancet, or by 
leeching, or by both, will be necessary, and should be early used. 

15. The most satisfactory emetic for employment in such cases is a 
combination of ipecac, and alum [F. 24] ; the latter being used in half 
teaspoonful doses in urgent cases, until emesis is produced. Xor 
should the practitioner hesitate to compel repeated vomiting at inter- 
vals, in desperate cases. Better for a child to risk being sick for a 
month, than to die of cynanche (dog-choke, as the Greeks termed it). 
But the alum is unlikely to do harm. 

16. Tartar emetic should not be used as an emetic in croup ; in 
sedative or expectorant doses, it may be advantageous. 

IT. Calomel [F. 25], freely administered, that is. a grain every hour 
or two. has the highest authority in its favor, in serious croup. 

18. Nitrate of potassa has both experience and reason in its favor. 
Being a solvent of fibrin, it should tend to prevent the excessive 
coagulability of the exudation. According to late theories, ammonia 
might do the same thing: but the clinical or therapeutic antecedents 
of ammonia point otherwise. Of the lately asserted value of sulphur 
in croup. I have no experience. 

19. The great evil in membranous croup is the solidifying tendency 
of the exudation : why should not. therefore, an abundant imbibition 
of fluids, even of water, do something towards the counteracting of 
this? Iuhalation of steam, from hot water poured upon unslaked 
lime, is eulogized by several recent writers. Glycerin, in teaspoonful 
or half teaspoonful doses, is recommended by others. 

20. Xo clear indication exists for the use of opium in the majority 
of cases of inflammatory or membranous croup : although it may 
become useful, in cases which are protracted, or which are attended 
by a more than usual disposition to spasmodic symptoms. 

21. Blisters are decidedly useful ; but they should not be left on 
long in croup, a superficial vesication only being desired. 

22. The application of a strong solution of nitrate of silver [F. 26] 
to the fauces (and larynx, if possible), does good in many cases : in 
the pre-exudative stage, as a medicament: in the exudative, as a me- 
chanical operation aiding to dislodge the membrane. 

23. Iodide of potassium is too slow in its systemic action to be 
relied on: and the same may be anticipated of the bromide, although 
nothing should forbid their fair trial. 

24. Tracheotomy or laryngotomy will, when performed early, suc- 
ceed in a fair number of cases; but in those very cases it is impossible 

12* 



138 DISEASES OF ORGANS OF RESPIRATION. 

to know that they (as well as those in which it fails) might not have 
recovered without it. Few practitioners, therefore, in this country, 
can demand the operation early ; and in the moribund state, the vascu- 
lar congestion, from asphyxia, about the throat, renders success ex- 
tremely difficult, sometimes impossible. Upon the whole, therefore, 
the number of cases in which the operation may be expected to add 
anything to our hope in croup, are few indeed ; about as few as those 
in which careful surgery would justify ovariotomy. In 1859, Bouchut, 
of Paris, introduced tubage (or catheter-like dilatation of the larynx 
and trachea) instead of tracheotomy, at the same time publishing 
some statistics very unfavorable to tracheotomy. The Aeademie 
Imperiale de Medeein, however, decided adversely to the use of tubage 
as a substitute for tracheotomy. The possible extension of false 
membrane into the bronchial tubes is an objection to tracheotomy as 
well as to tubage in croup. 

My own experience with tracheotomy, having met with four fatal 
disappointments, led me to abandon it in practice. I cannot, however, 
justify this as an absolute principle. With Dr. C. West, who has had 
but one recovery in sixteen cases, I am obliged to admit its success, 
in some otherwise hopeless instances ; especially in France, where 
Trousseau and others operate earlier than in England or here. It is 
most generally fatal in children under three years of age. Where 
there is reason to suppose the membrane to extend into the bronchial 
tubes, it is of course in vain. The danger of hemorrhage is least if the 
operation is early. 

If performed, it should be deliberate, making a considerable opening 
in the trachea, and inserting a tube or canula of good size. Then the 
patient should be surrounded constantly with a warm, moist atmos- 
phere. . The canula should be withdrawn in as few days as possible, 
upon the return of permeability of the larynx. The wound may then 
be treated with ordinary mild dressings to exclude the air and heal 
it up. 

Lately, the fact that lime will dissolve false membranes has been 
applied to the treatment of croup ; by making the patient breathe the 
steam from boiling water poured over unslaked lime. Although the 
lime is not volatile, some of its minute particles will be raised mecha- 
nically by agitation. Several successful cases of its use are reported. 
I should think the practice worthy of further trial. 

To sum up, I would begin the treatment of a case of inflammatory 
croup with a saline purgative. Then an emetic of ipecacuanha; 
which may have to be repeated. Leeching, and even venesection will 
be useful in a robust subject if seen early. Between the times of 
emesis, there may be prescribed 1 grain of calomel with 5 grains of 
nitrate of potassa, every two hours ; in urgent cases every hour. In 
children over three years of age, ^ to T ^ grain of tartar emetic may 
be added. The warm bath, prolonged, may be used once or twice 
daily. Warm poultices, or cloths wrung out of cold water (which 
soon becomes warm when applied) may be applied to the throat ; but 
a blister should follow in a severe case. Inhalation of steam from 
lime should be tried, early as well as late. Alum must be added to 
ipecac, if relief be delayed. Nitrate of silver sponging, and trache- 
otomy, are the last resorts. 



PHTHISIS PULMONALIS. - 139 



PLEURODYNIA. 

Synonym. — Intercostal Rheumatism. 

Symptoms. — Pain, generally rather dull, sometimes quite severe, 
of one or both sides, oftenest on the left. It is increased by deep 
breathing or coughing, moving the arms or trunk. 

Diagnosis. — From pleurisy, it is known by the absence of fever, 
and of all modifications of the sounds heard upon percussion and 
auscultation. 

Treatment. — A large mustard plaster over the part; friction with 
soap or volatile liniment ; dry or cut cups ; a blister if obstinate as 
well as severe. 

INTERCOSTAL NEURALGIA. 

Symptoms. — Severe lancinating pains between the sixth and ninth 
or tenth ribs, along the intercostal spaces ; frequently intermitting, or 
even regularly periodical. This affection is most generally met with 
in anaemic patients, or in those who have been exposed to malarial 
influence. Occasionally the paroxysms are attended by a sort of reflex 
pulmonary congestion, simulating pleuro-pneumonia. 

Treatment. — Liniment of aconite [F. 27], or of chloroform [F. 
28], or ointment of veratria [F. 29], may be rubbed upon the side 
during the paroxysm. Should these not relieve, a moderate or small 
blister may be allowed to vesicate, and then one or two grains of ace- 
tate of morphia diluted with powder of gum arabic may be applied to 
the surface; or solution of morphia may be used by hypodermic in- 
jection, half a drachm at a time being introduced by means of the 
syringe adapted to the purpose, over the part. 

General treatment, by iron, quinia or cinchonia, &c, will be deter- 
mined by the condition of the patient. 

THORACIC MYALGIA. 

This term has recently been applied to an affection characterized 
by pain in the superficial muscles of the chest, mostly dependent upon 
ill nourishment and overwork; sometimes produced by constrained 
positions of the body, or pressure ; as by a desk, or a soldier's belt, 
&c. 

Its treatment consists in the removal, if possible, of its cause ; with 
local calorifacient or anodyne applications, and general invigoration of 
the system. 

PHTHISIS PULMONALIS. 

Definition. — Tuberculous consumption of the lung3. 

Varieties. — Acute, chronic, and latent phthisis. 

Symptoms and Course. — Consumption may begin after a severe 
acute bronchitis ; or, more gradually, with an apparently slight hack- 
ing cough ; or with a hemorrhage ; or with dyspepsia and general 
debility; or with chronic laryngitis. Increasing, in most cases slowly, 
the pectoral and constitutional disorder becomes developed. "We 



140 DISEASES OF ORGANS OF RESPIRATION. 

have, then, pains in the chest, frequent and severe cough, hemorrhage 
occasionally (in about two thirds of the cases) and pallor, acceleration 
of the pulse and elevation of the temperature, with the paroxysms of 
hectic fever, i. e., chills followed by fever with bright Hush of cheek 
but without headache ; emaciation, arrest of menstruation in the 
female, night-sweats, colliquative diarrhoea; finally, often, though not 
always, delirium ; and death, mostly by exhaustion, but sometimes by 
suffocation. The spirits of the patient are apt to be cheerful, even 
hopeful of life almost to the last. Appetite is variable, digestion 
usually not vigorous ; but to this there are exceptions. 

The following description of advanced phthisis is from the late 
Prof. N. Chapman : — 

" The cheeks are hollow, the bones prominent, the skin arid, the 
nose sharpened and drawn, the eyes sunken, with the adnata of a 
pearl color, destitute of vascularity, the lips retracted, so as to pro- 
duce a bitter smile, and the hair thinned by falling out, the neck wasted, 
oblique and somewhat rigid or immovable, the shoulder blades pro- 
jected or winged, the ribs naked or exposed, with diminution of the 
intercostal spaces, and the thorax apparently narrowed ; the abdomen 
flat, the joints, great and small, seemingly enlarged from the wasting 
of the integuments, the nails livid, and occasionally incurvated, the 
extremities cedematous ; the angular points on which the body rests, 
in several points protruded through the skin, — the whole attended by 
a most afflicting cough, aphthae, sore throat, difficult deglutition, and 
feeble, whispering voice, or entire extinction of it." 

The expectoration in phthisis is at first mucous or bloody ; later, 
muco-purulent and bloody, or else nummular ; i. e. in roundish masses 
like coins, not floating perfectly in water ; or, abundant and purulent. 

Stages. — These are, 1. Incipient phthisis ; 2. The stage of consoli- 
dation of the lung; 3. That of excavation or vomicae,; 4. Advanced 
or confirmed consumption. 

Physical Signs. — Is there a pre-tubercular stage of phthisis ? If 
so, it cannot be certainly pronounced upon. The earliest indications 
upon physical exploration are, a sinking in under the clavicle upon 
the left side, with prolonged expiratory sound. Not long after, the 
evidence of consolidation is, increased dulness over the apex of the 
lung upon percussion (not invariably but generally upon the left side) 
with blowing or bronchial respiration, or interrupted jerking respira- 
tory murmur, and increased vocal resonance and vibration. Dry 
crackling follows with mucous or coarse crepitant rale. 

When softening of tubercular deposits occurs, moist crackling and 
gurgling become very distinctive signs. The presence of a, vomica is 
shown by cavernous respiration and bronchophony or pectoriloquy. 
Percussion resonance over a cavity will be dull if its walls be thick, 
and amphoric if they are thin and tense ; if thin and relaxed, the bruit 
depotfele or cracked pot sound. On percussion over a cavity when 
the patient's mouth is shut, the sound produced will be of a lower 
pitch than when the mouth is open. 

Pneumothorax and hydropneumothorax, i. e., dilatation of the 
pleural cavity and compression of the lung by air, or air and liquid 
together, with perforation of the lung, are not uncommon results of 
tuberculization, although possible without it. Of pneumothorax, the 



PHTHISIS PULMONALIS. 141 

percussion resonance is tympanitic : respiratory murmur lost. Hydro- 
pneumotborax may give tympanitic resonance above, with metallic 
tinkling, on auscultation, and dulness below. 

Physical and Microscopical Peculiarities.— Temperature has of 
late been found to be a diagnostic aid in phthisis. It is asserted that 
there is a continued elevation of the heat of the body in all cases in 
which tubercle is being deposited ; that this may occur for weeks 
before any local physical sign is discoverable ; and that the rise in 
the heat of the body varies, during the progress of the case, with the 
greater or less activity of the tuberculization. 

When expectoration is copious, some micrologists aver that diag- 
nosis may be aided by its minute characters ; arched and anastomosing 
fragments of pulmonary fibrous tissue, and tubercular corpuscles, being 
discerned. But it is not certain that the former are only thrown off 
in phthisis ; and the latter may be absent or obscure in character in 
an otherwise clear case of consumption. Dr. Fenwick. of London, 
detects minute portions of lung-tissue by boiling the expectoration a 
few minutes with its bulk of solution of caustic soda (gr. xv in f5J of 
distilled water), and then adding cold water, in a conical vessel. The 
sediment is then examined with the microscope. 

Terminations, — The cicatrization of vomicae, and the cessation of 
tubercular deposition, have, although exceptional, been often found 
to occur; and so have the cornification and calcification of unsoftened 
tubercle. Recovery from phthisis may in such cases be expected to 
take place, as the arrest of the local disease only attends the presence 
of a favorable constitutional state. 

Death from consumption may come by asthenia or by apnosa. The 
first is most common. Suffocation or apnoea may follow — 1. from 
hemorrhage: 2. rupture of a large vomica; 3. pulmonary oedema or 
hydrothorax ; 4. excessive secretion or bronchorrhcea, beyond the 
power of expectoration. 

Complications. — Pleurisy is a frequent concomitant of phthisis. 
Tubercular peritonitis is much more rare. On account of its dura- 
tion, however, this disease may be accidentally combined with various 
affections not specially kindred with it. Asthma is particularly not 
apt to be conjoined with phthisis. 

Diagnosis. — It is from chronic bronchitis, cancer of the lung, pleu- 
ritic effusion, bronchial dilatation, and pulmonary abscess that phthisis 
requires the most care for discrimination. 

Chronic bronchitis is not common except in old persons : its expec- 
toration is thinner, whiter, and not nummular nor bloody; there is no 
hectic, although there may be emaciation; and there are none of the 
physical signs of phthisis. 

Cancer of the lung exhibits a marked dulness of resonance on per- 
cussion on one side, with blowing respiration, unless a bronchial tube 
be obstructed, when there is no respiratory sound. There is severe and 
almost constant pain in the chest. The peculiar auscultatory si°ns 
of tubercular disease are absent : and the sallow, cachectic aspect of 
cancer, and the concurrent existence of carcinomatous tumors some- 
where in the body, generally make the case clear. 

In "chronic pleurisy,'" as pleuritic effusion is often called, the dulness 
on percussion is at the lower part of the chest ; the side is expanded, 



142 DISEASES OF ORGANS OF RESPIRATION. 

unless after the fluid is absorbed ; respiratory murmur and vocal vibra- 
tion are suppressed ; and the general symptoms, as irritative fever and 
wasting, are not so extreme. 

Bronchial globular dilatation may give auscultatory signs exactly 
like those of a tubercular cavity ; but there is no haemoptysis, nor 
emaciation, nor much loss of health. The expectoration may be more 
copious than in consumption ; but the matter is more liquid, and pus 
is much more diffused in it. The cough is more constant than in 
phthisis. 

Abscess of the lung is to be distinguished from phthisis by its his- 
tory, generally following recognized pneumonia; its seat mostly at the 
base of the lung ; its physical signs decreasing instead of increasing ; 
and, as with cancer, the affection being confined altogether to one 
lung. The extension of the signs to both lungs is important in most 
cases in the diagnosis of phthisis. 

Syphilitic disorder sometimes affects the lungs and bronchial tubes, 
with a condition almost undistinguishable from ordinary consumption. 
The previous existence of venereal disease, and periosteal nodes upon 
the clavicles, with the slower progress of the decline, will help to en- 
lighten us. 

Prognosis. — Phthisis is certainly one of the most destructive of 
diseases. In no case can recovery be anticipated ; but it does occur, 
as every physician must have witnessed. I" have seen several such 
recoveries ; generally from the incipient stage, but even where vomicae, 
emaciation, and night-sweats had occurred. Dr. A. Flint has recorded 
the history of sixty-two cases of restoration from consumption. 

Under improved hygiene and medical treatment, the mortality from 
phthisis appears to be declining. Without referring to statistics (the 
nomenclature connected with which in past times would be a source 
of doubt, as chronic bronchitis. &c. were once called consumption), I 
am convinced that fewer people die of phthisis now than twenty-five 
years ago, in Philadelphia. 

The duration of phthisis varies greatly, being least, as a general 
rule, in the youngest subjects. Eighteen months to two years is the 
most frequent period. But in some instances life is prolonged under 
it for twenty, thirty, or even forty years. 

Acute phthisis, or galloping consumption, may end life in from six 
weeks to three months. This sometimes follows pneumonia. Its 
symptoms differ from those of ordinary consumption chiefly in their 
rate of progress. Softening of the tubercle and the formation of 
cavities do not always occur to any extent, apncea being caused by 
extensive diffusion or infiltration of the tuberculous deposit through 
the lungs. 

In any case of consumption, the state of the general system is of pri- 
mary import in prognosis. When the patient is gaining in weight and 
strength, and fever and night-sweats diminish or disappear, there is 
hope, for a time at least. Spitting of blood (when consumption is 
proved to exist already) does not increase, but rather lessens the un- 
favorable aspect of the case. Rapid emaciation, chills, hectic, swell- 
ing of the feet, and diarrhoea are always discouraging ; as, of course, 
are. also, all signs of increase in the local pulmonic affection. 

Causation. — Hereditary taint of constitution is general ; indepen- 



PHTHISIS PULMONALIS. 143 

dent origination of phthisis the exception. From 18 to 35 years is 
the time of life most subject to it ; but it is now and then met with 
even in children, and frequently in the aged. Statistics in Europe 
and this country show some proportion between the mortality from 
consumption and nearness to the sea level; the lowest lands having 
the greatest total amount of it. High, dry, and equable climates and 
situations, even though cold, are most exempt from it. It is not a 
disease of the Arctic regions, and there is more of it in South Carolina 
than in Maine. 

Individually, and in families, all causes that depress vitality promote 
it ; but most of all impure atmosphere. Sedentary employments and 
exhausting excesses, with foul air, make large cities most of all pro- 
ductive of it. ]n constitutions having the proclivity towards it, 
tuberculization may be brought on by any reducing disease, especially 
such as involves the breathing organs ; as measles, bronchitis, or 
pneumonia. 

Treatment. — Hygienic management is, decidedly, more important 
to the consumptive than medicine. The following precepts are well 
laid down by Dr. B. W. Richardson: — 

1. A supply of pure and fresh air for respiration is constantly re- 
quired by the tuberculous patient. 

2. Daily exercise in the open air is imperatively demanded by the 
tuberculous patient. 

3. It is important to secure for the patient a uniform, sheltered, 
temperate, and mild climate to live in, with a temperature about 60°, 
and a range of not more than 10 or 15° ; where, also, the soil is dry 
and the drinking water pure and not hard. 

4. The dress of the tuberculous patient ought to be of such a kind 
as to equalize and retain the temperature of the body. 

5. The hours of rest should extend from sunset to sunrise. 

6. In-door or sedentary occupation must be suspended ; but out- 
door employment in the fresh air, even in the midst of snow, has been 
and may be advantageous. 

7. Cleanliness of body is a special point to be attended to in the 
hygienic treatment of tuberculosis. 

8. Marriage of consumptive females, for the sake of arresting the 
disease by pregnancy, is morally wrong and physically mischievous. 

Altogether, the analeptic principle is now universally adopted for 
the treatment of consumption. The diet must be nourishing ; a 
•* generous" regimen ; and the same indication is to be followed in the 
employment of medicines. 

There has been discovered, as yet, no specific to arrest tuberculosis. 
But cod-liver oil and alcohol, and, in lesser potency, iron, quinine, and 
other tonics, in a certain number of cases "do manifest an important 
conservative and restorative influence ; and palliation of symptoms, 
as pain, cough, loss of rest, may greatly help the comfort of the patient. 
My confidence in the frequent value of cod-liver oil is based chiefly 
upon observation. Three individuals in one family, for example, under 
my care, notwithstanding a well-marked family tendency (shown by 
the previous death by phthisis of three sisters, a mother, and uncle), 
recovered from incipient consumption under the use of the oil. Other 
cases, much more commonly, have life prolonged by it. Unfortu- 



144 DISEASES OF ORGANS OF RESPIRATION. 

nately, however, in quite a considerable number of persons the stomach 
turns against cod-liver oil. When that is the case, it is quite in vain 
to urge it. It may be taken in the froth of porter or ale, or after 
rinsing the mouth with brandy, which may also follow it. Some dis- 
like it less when salted. Ammonia added to the oil lessens its taste ; 
but I have never tried the combination extensively. The gelatinous 
capsules make it much less disagreeable to swallow ; but less than two 
or three tablespoonfuls of the oil daily will hardly suffice. It can 
always be taken best in cold weather [F. 30, 31, 32]. 

Alcohol, though variously estimated by different physicians, is, in 
my view, well established as a remedial or at all events a supporting 
agent of value in consumption. Not to be used in excess, nor ever 
to produce excitement in any degree ; but simply as a roborant ; as 
an addition to the diet and a supporter of the strength of the invalid. 
The dose must, therefore, be proportioned to his condition. 

Whisky is preferred by many ; but ale, lager beer, and wine suit 
different patients best. A little two or three times daily will be better 
than a full drink at one time. I would always begin with very small 
quantities — say two or three teaspoonfuls of whisky, or half a glass 
or even less of wine, or half a tumblerful of ale or beer. To do good, 
the stimulant should not quicken the pulse, flush the face, or be felt to 
affect the head. Kept under such restrictions, even when increased 
to meet greater prostration, I have never known any hankering after 
excess to be caused by it. One patient of mine, with phthisis, would 
sometimes, when temporarily much reduced, take more than half 
a pint of whisky daily for a time : and then, as his strength rallied, 
would diminish the amount to almost none, without any difficulty or 
longing for more. 

Lately, we hear from abroad of great advantage accruing from the 
" raw beef and brandy" treatment for consumption ; but I am not 
possessed of the particulars of it. When it can be done, alcoholic 
stimulus is best given with nourishment, as in milk, or beaten up with 
a raw egg, &c. 

Beef-tea, as a concentrated nutrient, is very useful when digestive 
power is low, at any stage of phthisis. One lady under my care, who, 
with tussicula, haemoptysis, and emaciation, had greatly the appear- 
ance of incipient consumption, and who could not retain cod-liver oil 
upon her stomach without loss of appetite, was put upon the daily 
use of a pint of strong beef-tea, 1 for several weeks together ; with no 
medicine except a mild expectorant. She recovered, and has since 
married and become a mother. 

The phosphates and hypophosphites of lime, &c. have been suffi- 
ciently tried to prove their inferiority to cod-liver oil. My own ex- 
perience with them, in the wards of the Episcopal Hospital in this 
city, as well as in private practice, has been discouraging; and I 

1 The mode of preparation of beef-tea is not unimportant. I prefer the fol- 
lowing : Cut up a pound of good lean beef into small pieces, pour upon it a 
pint of cold water, and let it stand two hours beside the fire. Then boil it 
half an hour. Take off all the scum and oil drops, carefully ; but do not filter 
or strain it. It should have a rich brown color; and, with salt, is agreeable 
to the taste. 



PHTHISIS PULMONALIS. 145 

believe the best phosphate for analeptic use to be the phosphate of 
iron. Chlorate of potassa has also entirely failed under fair trial. 
Glycerin will not take the place of cod-liver oil ; nor has any other oil 
been shown to be capable of doing so. 

Iron, especially the iodide [F. 33] and the tincture of the chloride, 
are frequently suitable ; and so may be quinine, nux vomica f F. 34] , 
or the simple bitter tonics. But the patient must not be worried and 
disgusted with much medicine ; whatever depresses appetite is likely 
to do more harm than good. 

For this reason, expectorants require discretion in their use. Those 
of a nauseant kind must be very sparingly prescribed in phthisis. The 
syrup or fluid extract of wild cherry [F. 35, 36] is one of the most 
suitable. Squills will do when loosening effect is particularly required. 
Ipecac, and tartar emetic are too depressing to the stomach for the 
consumptive. Sometimes, at a late stage, carbonate of ammonia will 
not be too stimulant. 

Anodynes and calmatives are almost always wanted as the case 
advances, to soothe the wearisome cough, and to give rest at night. 
Lactucarium, hyoscyamus, and finally opium, or morphia, in some 
form, will be important sources of comfort to the patient, and may 
economize his strength. 

The colliquative sweats seldom demand treatment, they being the 
result rather than the cause of debility. Ablution with brandy or 
whisky and alum may be practised if they are very excessive. 
Diarrhoea may require to be held in check, by simple astringents with 
opiates. 

If pleurisy or peritonitis supervene as a complication, the local in- 
flammation must be treated in view of the general condition. Deple- 
tion is out of the question at an advanced stage. Dry cups, blisters, 
and opium are all that we can use in the treatment. For the variable 
pains in the chest in the course of the disease, mild or moderate 
counter-irritation, by warming plasters, tincture of iodine, or croton 
oil, may be used. 

It is not, however, to be said that the name or character of phthisis 
should in all cases rule out local depletion in the incipient stage. In 
one of three cases in one family (already alluded to) who recovered, 
notwithstanding a strong inherited tendency to consumption, from a 
condition threatening it, great relief and improvement followed the 
application of two dozen leeches to the side ; it was (to borrow an ex- 
pression of Dr. Condie's) at the time, an acute tuberculous pneumonia. 
Yet I know that such cases are exceptional. The pervading indica- 
tions in phthisis are economy and recuperation. 

Inhalation has often been tried, in phthisis. Not enumerating 
agents which have summarily failed, I believe the best hope attaches, 
in this way, to inhalation of the vapor of creasote or of carbolic acid. 
These agents are styptic, and creasote, at least, by its power of coagu- 
lating albumen and albuminoid material, may be expected to aid in 
arresting the softening and destructive process in the lung. At least, 
we might hope that it would (and in some cases it has proved so) 
lessen excessive and exhausting expectoration. 

Change of climate is often proposed for the benefit of the consump- 
tive. In an early, or middle, or even a stationary advanced stage, it 
13 



146 DISEASES OF ORGANS OF RESPIRATION. 

may be of important advantage. When to forbid, or advise it, may 
be a very delicate question. More will depend upon the rate of pro- 
gress than upon the period of the case. But the patient must have 
strength enough to travel, and must be not too dependent upon his 
home comforts, or he may be made worse instead of better. It is a 
cruelty to banish one who is already on the verge of the grave to die 
in a strange place among strangers. Yet I have known life to be 
prolonged from year to year, in one who was a native of this city, by 
his spending the winter south. 

In selecting a climate for the invalid, equability and dryness are, 
unless at a late stage, more important than warmth. That climate 
which will allow the patient the greatest number of days out of doors, 
will be the best. Minnesota, and other places near Lake Superior, 
agree extremely well with some. Of southern localities, Florida pre- 
sents an especially equable, almost maritime, climate. Cuba is often 
resorted to. A sea voyage (if not subject to exhausting sea-sickness) 
may do good at an early stage. Across the ocean, consumptives re- 
sort to the South of France, particularly to Pau or Biarritz ; or to 
Mentone, or Malaga, or Malta ; or Italy, — especially Ischia or Capri, 
Sorrento or Palermo ; — Madeira, and Algeria, the year round, and 
Egypt in the winter only, are favorite climes. For the winter, nothing 
could excel in salubrity the atmosphere of the upper Nile. 

Our own country affords all the requisites for the migrations of an 
invalid, to escape the inclemencies of every season, if he can vibrate 
between Newport, R. I., in the summer, and St. Augustine or the 
interior of Florida for the winter. 

Phthisis in Early Life. — Dr. C. West 1 names the following as cha- 
racteristics of consumption in children, among whom, however, it is 
certainly rare : — 

1st. The frequent latency of the thoracic symptoms during the early 
stages. 

2d. The almost invariable absence of haemoptysis at the commence- 
ment of the disease, and its comparatively rare occurrence during its 
subsequent progress. 

3d. The partial or complete absence of expectoration. 

4th. The rarity of profuse general sweats ; and the ill-marked cha- 
racter of the hectic symptoms. 

5th. The frequency with which death takes place from intercurrent 
bronchitis or pneumonia. 

The same excellent authority designates the following peculiarities 
in the auscultatory phenomena of consumption in the child. 

1st. The smaller value of coarse respiration, prolonged expiration, 
and interrupted breathing, owing to their general diffusion over the 
chest, and to their occasional existence independent of phthisis. 2 

2d. The greater difficulty of distinguishing chronic bronchitis, in 
the child, from phthisis. 

3d. The loss of that information which the phenomena of the voice 
furnish in the case of the adult. 

1 Diseases of Children, p. 404. 

2 The occurrence of harsh respiratory sound as an initial sign in pneumonia 
of children is well established. 



PERICARDITIS. 14V 

4th. The smaller value of inequality of breathing in the two limes. 

5th. The difficulty of detecting minute variations in the resonance 
upon percussion. 

6th. The frequent existence of dulness in the interscapular region, 
with moderate resonance and tolerably good respiration in the upper 
part of the chest, — characteristic of enlargement of the bronchial 
glands. 

AFFECTIONS OF THE ORGANS OF CIRCULATION. 

PERICARDITIS. 

Definition. — Inflammation of the covering membrane of the heart 

Varieties. — Simple or idiopathic, and rheumatic pericarditis. The 
latter is very much the more common. Degrees of violence in the 
attack also cause variations, from the mildest and almost latent cases, 
through those of open and active severity, to those attended by rapid 
effusion and prostration. 

Symptoms. — Fever; pain (occasionally absent) at and radiating 
from the heart; tenderness on pressure in the cardiac region; accele- 
rated, irregular, or oppressed, rapid and feeble pulse : anxiety or 
delirium ; nausea and vomiting in some cases : short hacking cough ; 
towards the end, coldness and pallor or lividity. cedema of the face 
and extremities, loss of pulse. 

Stages. — 1st. Acute inflammation: 2d. Adhesion: 3d, Effusion. 

Physical Signs. — Before adhesion or effusion, usually, exaggeration 
of the heart's impulse. Then. peTicardudfriction-sounds (to and fro) ; 
the vibration of which is sometimes felt by the hand. After effusion, 
dulness on percussion, with muffling of the heart's sounds to the ear 
on auscultation. The friction-sounds disappear during this period, 
sometimes to return as the effusion is absorbed. 

Morbid Anatomy. — In the first stage, there is a rose-redness of the 
pericardium, diffused, punctated or in patches. Then, deposits of 
coagulable lymph, white and opaque, sometimes causing local or gene- 
ral adhesion of the two layers of serous membrane. In most fatal 
cases, effused serum is found in the sac. in quantity varying from 
ounces to pints. Great quantities of it weigh down the diaphragm 
below it. Purulent exudation is sometimes met with. In scorbutic 
cases, it may be hemorrhagic. 

The muscular tissue of the heart is usually less coherent than usual. 

Diagnosis. — From endocarditis and from pleurisy it is sometimes 
not easy to distinguish pericarditis. The symptoms of the latter and 
those of endocarditis are the same: and the friction-sounds occur in 
both. The heart's impulse is more apt to be sustained in strength in 
endocarditis: and, in the latter, no dulness on percussion occurs, nor 
are the heart-sounds muffled at any stage ; while valvular murmurs 
follow endo- and not pericarditis. 

Friction sounds which are outside of the heart (pericardial) have a 
nearer character to the ear than endocardial sounds: they are more 
narrowly limited, not passing along the vessels; they do not keep 
exact time with the cardiac sounds, and may vary from day to day; 
and sometimes the vibration may be felt externally. 



148 DISEASES OF ORGANS OF CIRCULATION. 

Pleurisy causes friction sounds, and afterwards dulness on percus- 
sion. But, the former sounds are more diffused, are generally single, 
not "to and fro" or double ; and the dulness extends further over and 
around the side. Latent pericarditis may possibly, from some symp- 
toms, be taken for inflammation of the brain, or of the stomach. Phy- 
sical exploration should prevent such errors. 

Prognosis. — There is great danger to life in pericarditis ; and its 
course is sometimes terminated by death in a few days. In other 
cases resolution may take place promptly ; but more often the heart is 
clogged for a considerable time (weeks or months) with effusion, or a 
more protracted interference occurs from adhesion of the pericardial 
surfaces. This latter is sometimes shown by a dimpling, or sinking in, 
with each beat of the heart, of the intercostal spaces above and below 
it. 

Causation. — The materies morbi of rheumatic fever is far the most 
common cause of pericardial inflammation, as it is of endocarditis 
also. Gout is accused of the same thing ; but with much less fre- 
quency, or indeed, clearness of proof. Bright's disease of the kidney 
is occasionally associated with it. 

Treatment. — In active cases, and good subjects, one early and 
moderate bleeding from the arm will be proper Afterwards, in some, 
and instead with feebler patients, whose fever is high and pain intense, 
leeches over the cardiac region may be used. A brisk saline cathar- 
tic, as Epsom or Rochelle salts, or citrate of magnesia, should com- 
mence the medication. Calomel, trusted still by some and abused by 
others, may be confined to open sthenic cases, in previously good 
constitutions. In such, I would give half a grain of calomel, with 
half a grain to a grain of opium, thrice daily for three or four 
days. 

Where the rheumatic diathesis is marked, alkalies [F. 37] will be 
indicated. Carbonate or bicarbonate of potassa, or bicarbonate of 
soda may be given, in scruple or half-scruple doses, with as much 
of Rochelle salts, three or four times a day. A blister over the heart, 
as the fever lowers, will often have a very good effect. If effusion 
occur, blistering may be repeated. 

Should no opiate be given through the day, Dover's powder or 
morphia may be prescribed at night. 

For the stage of effusion, or " chronic pericarditis," the usual treat- 
ment consists of diuretics [F. 38, 39, 40] , as squills, juniper, sp. aeth. 
nit. dulc, etc., varied and continued until absorption occurs. Tonics 
will often much promote the same end. 

A rapidly depressing, case of pericarditis, with cold, blue skin and 
feeble, irregular pulse, will require, instead of the above, a supporting 
or stimulating treatment from the first ; with dry cups and blisters 
instead of local or general bleeding; and quinine, ammonia, and 
brandy, instead of sudorifics or laxatives. 

Myocarditis is inflammation of the muscular substance of the heart. 
It can hardly be said to have other than a nominal existence. 






ENDOCARDITIS. 149 



ENDOCARDITIS. 

Definition. — Inflammation of the lining membrane of the heart. 

Symptoms and Physical Signs ; Diagnosis.— These have been 
sufficiently stated in the account just given of pericarditis and its 
diagnosis, and need not be repeated. Like that disease, it is most 
often of rheumatic origin ; but may occur in Bright' s disease or in 
pyaemia. 

Valvular derangement and its signs give great interest to endocar- 
ditis and its resulting changes. Mostly it is the left side of the heart 
that is chiefly affected. The simplest and most common sign of this 
is a blowing sound, heard on auscultation. But a bellows murmur is 
heard also in cases of anaemia, and a blowing sound occurs not rarely 
in fevers ; or it may belong to an organic heart-affection of long stand- 
ing. This last fact should be ascertained by the history of the 
patient, as well as by the aid of symptoms ; but the old murmur is 
generally rougher and more fixed in its seat. It is possible, though 
very rare, for endocardial inflammation to be located so far from the 
valves as to cause no blowing sound. 

Clots sometimes form in the heart, in endocarditis (as well as in 
some other diseases attended by prostration), obstructing the circula- 
tion, even to a fatal extent. Although most clots are post-mortem in 
origin, there is no doubt that sometimes firm fibrinous masses do 
occlude the valves for some time before death. The symptoms pro- 
duced are, blueness and coldness of the skin, indistinctness of the 
heart-sounds, feebleness and irregularity of the pulse, nausea and 
vomiting, anxiety of expression, and fainting. 

Much more often, vegetations or fibrinous deposits of exudation on 
the valves of the heart are carried in fragments therefrom by the blood 
into the arteries. Being arrested, as in a vessel of the brain, or a 
limb, etc., the condition of obstruction designated as embolism results; 
which receives attention in another part of this book. Old valvular 
vegetations, as well as the recent ones of endocarditis, may give rise 
to emboli ; which may, also, arise from coagulation in a vein, or throm- 
bosis. 

Endocarditis produces valvular derangement in the mitral valve 
most frequently in the young ; in the old (from this cause as well as 
from degeneration), disease is rather more common in the aortic valve. 
The forms of disorder, indicated by murmurs, occur in the following 
order of frequency : 1st. Aortic obstructive; 2d. Mitral regurgitant; 
3d. Aortic regurgitant ; 4th. Aortic obstructive and mitral regurgi- 
tant together. 

Enlargement of the heart, either with muscular thickening (hyper- 
troplxy) or with attenuation (dilatation) is a common consequence of 
endocarditis with valvular lesion. Already (see Semeiology) the state- 
ment of Dr. Stokes has been adopted, that in every case the important 
question is, less the state of the particular valves, than the amount of 
interference with the functional action of the heart. In young persons, 
remarkable recoveries sometimes take place (as I have seen) from very 
considerable lesion of the valves. In other instances, adaptation of 
the heart itself, and of the general system, by degrees, is effected, so 
that quite good health, and even capacity for exercise, may be attained, 

13* 



150 DISEASES OF ORGANS OF CIRCULATION. 

while the physical signs of the local organic change remain. Sudden 
death is less common in heart-disease than is popularly supposed. 
Some persons having it have lived twenty or thirty years. 

VALVULAR DISEASE. 

The valves of the heart may be impaired either by inflammation, or 
by degeneration (e. g. calcareous deposit or "ossification"). The 
latter, degenerative valvular changes, occur gradually ; and mostly 
late in life. Either form of valve-disease, or at least of valvular 
alteration, is generally permanent ; the degenerative form almost in- 
variably so. 

Changes may occur, by simple thickening, or by deposits of fibroid, 
fatty, or calcareous material ; or by atrophy, contraction, adhesion, or 
ulceration of the valves; or gouty deposits, of urates and carbonates 
of soda and lime. The valve (mitral or aortic primarily, or tricuspid 
or pulmonary secondarily') may be thus rendered incapable either of 
perfect closure, or of ftiffl opening ; in most instances, at least, a per- 
manently half-open state results. 

A considerable variety of pathological conditions may exist in 
organic disease of the heart ; while the number of cases in which an 
exact and unequivocal diagnosis can be made, is comparatively small. 
We must not confine attention at all to the physical signs alone, but 
compare also with these the pulse, and force of the heart, with other 
general symptoms, and the entire history of the case. 

Certainty can hardly ever be obtained, unless it be in the diagnosis 
of one of the following three conditions : — 

1. Uncomplicated disease of the mitral valve. Signs of this are. — 
a permanent murmur, with the first sound, loudest towards the apex 
and left side, and not heard over the aorta ; the second sound natural. 
The heart's action natural ; the impulse not excited, the pulse natural. 

2. Disease of the aortic valves, with permanent openness. With 
this, there is no murmur with the first sound ; the second sound is re- 
placed by a double murmur, loudest at the base of the heart, and heard 
along the aorta. In an advanced stage of this condition, the arteries 
give to the finger, or even to the eye, an impression of bounding pulsa- 
tion ; with & jerking, or abruptly ending pulse at the wrist. 

3. Disease of the aortic valve, without permanent openness. Here, 
the action of the heart is slow and feeble, generally regular, or only 
occasionally intermitting. A murmur is heard with the first sound, 
the second sound being healthy ; but a murmur may be heard with the 
second sound, in the aorta and carotids. 

It must be noticed that in anaemia, without heart-disease, a bellows 
murmur is often heard, extending into the arteries. Chiefly by the 
concurrent signs and symptoms, is this to be distinguished from 
organic disease of the heart. Anaemic murmurs are more variable, 
and are not much increased by moderate exercise. 

When the aortic valvular orifice is greatly contracted, the pulse at 
the wrist may become very feeble, almost absent ; while the heart's 
impulse is strong. 

Advanced mitral or aortic disease is accompanied usually by de- 
rangement, sympathetic or obstructive, of the lungs, liver, and other 



DILATATION OP THE HEART. 151 

organs ; with haemoptysis, anasarca, cyanosis, irregularity of the pulse, 
syncope, &c. Pulsation of the jugular veins indicates secondary 
disorder upon the right side of the heart, with regurgitation into the 
venae cavae. Pseudo-apoplectic syncope may occur in permanent 
patency of the mitral valve ; or in fatty degeneration of the heart, with 
or without valvular disease. 

DILATATION OF THE HEART, yc 

Uncomplicated dilatation of the whole heart, or of either pair of 
corresponding cavities, or of any one cavity, is very uncommon. 
Complicated dilatation is frequent. It may depend — 1, on a debili- 
tated state of the cardiac muscle ; 2. on valvular disease ; 3. on 
obstruction beginning in organs remote from the heart. 

The commonest form of dilatation forms part of a triple affection, 
in which the heart, lungs, and liver are together involved. All this 
may come, in the first place, from a cachexia, such as gout, or scurvy, or 
from simple anaemia. Exacerbations in the disorder may occur ; as, of 
pulmonary congestion, enlargement of the liver, cardiac asthma, bron- 
chitis, or dropsy. The prognosis cannot be very favorable in such a 
case ; and only palliative, or recuperative, treatment avails, along 
with hygienic management, to economize the powers of nature. 

Dilatation of the heart is indicated, upon physical exploration, 
when, with extended impulse of the heart, we have dulness on per- 
cussion beyond the usual limits. If true hypertrophy, or muscular 
thickening, be present, the impulse is very forcible as well as extended. 
The heart-sounds are apt to be clear, though not loud, in attenuated 
dilatation ; rather loud, but dull toned, in enlargement with thickening 
of the walls. But these differences are hardly to be relied upon. 

Hypertrophy of the muscular tissue of the heart is most often 
induced by valvular obstruction or regurgitation, compelling unusual 
and continued effort to sustain the circulation. 

Sometimes, however, it is more truly idiopathic ; following causes 
of overaction of a heart otherwise sound. Thus violent exercise, self- 
abuse, coffee, alcohol, tobacco, &c, are, with good reason in predis- 
posed cases, accused of producing it. 

In the treatment of simple hypertrophy, avoidance of such ex- 
citing causes, and particularly of violent exercise, alcohol, and venery, 
is the main principle. Robust or plethoric patients will bear and be 
benefited by venesection, at long intervals ; or by occasional leeching 
or cupping over the heart. Acetate of lead [F. 41] , as an astringent 
cardiac sedative, is recommended by some, and is worthy of trial (one 
grain thrice daily), with care to avoid saturnine poisoning. 

Digitalis was formerly relied upon as a reducer of cardiac action. 
Lately the question has been opened widely, whether it does at all 
tend directly to lower the heart's action; or whether it is not, instead, 
a tonic to the heart (probably through ganglionic influence), lessening 
rapidity of action only when that depends on debility. The time has 
hardly come to pronounce upon this question. I think, however, that 
evidence has been given to encourage us to use digitalis [F. 42, 43] 
unhesitatingly where abnormal rapidity of the heart's action exists in 
conditions of debility ; and to expect more from veratrum viride [F. 



152 DISEASES OF ORGANS OF CIRCULATION. 

44] as a sedative and palliative, in violent acceleration of the pulse 
as in muscular hypertrophy, and in some forms of palpitation. 

FATTY DEGENERATION OF THE HEART, * 

Definition. — Substitution of fatty substance for the muscular tissue 
of the heart, to such an extent as to interfere with its normal action. 

Symptoms and Course. — Though no doubt almost always gradual 
in its progress, this affection in many instances fails to make itself 
known by symptoms until a late period ; sometimes even till the mo- 
ment of death. Usually, feebleness and irregularity of the pulse and 
heart's impulse are observed ; with exhaustion and dyspnoea upon 
exertion. The pulse is slow when at rest ; sometimes only thirty in 
the minute, although the heart beats fifty or sixty in the same time. 
Attacks of apoplectic syncope or syncopal apoplexy may occur ; at 
first most like syncope, after repetition becoming more apoplectic. 
These are distinguished from true apoplexy by the feebleness of the 
pulse, coldness of the skin, sighing respiration, and the slightness or 
absence of paralytic symptoms, notwithstanding several repetitions of 
the attack. They are made worse by depletion or reduction of the 
system ; and may be relieved or warded off by timely stimulation ; the 
recumbent posture is most favorable in them. The first attack of this 
kind may, however, prove fatal. 

Physical Signs.— Fatty degeneration is often complicated by the 
presence of other structural changes of the heart. By itself, it is with 
difficulty diagnosticated by physical exploration. The heart's impulse 
is feeble and slow, often irregular, and the sounds weak. A bellows 
murmur is frequently heard with one or both sounds. 

Morbid Anatomy. — True fatty degeneration must be distinguished 
from fatty accumulation about the heart; which may impede its action, 
but is much less dangerous. In true interstitial degeneration, the 
heart is, in part or throughout, flabby and pale or yellowish, though 
it may be more bulky than usual. Minutely examined, the muscular 
fibrils are found to have lost their transverse striae, and to have re- 
solved themselves, more or less, into streaks of oil-dots or opaque 
granules. 

Death, sometimes, is shown to have resulted from rupture of the 
heart. In other instances that organ has, under some exertion or 
excitement, become exhausted and failed to act sufficiently to keep 
up the circulation. 

Prognosis. — Recovery is not to be expected in cases of fatty de- 
generation ; although life may be prolonged to old age. Much will 
depend upon circumstances of living, and care to avoid disturbing 
agencies. 

Causation. — In early life this affection is uncommon ; its most 
frequent cause is, then, pericardial or endocardial inflammation. Most 
cases occur after fifty years of age. It then occurs as one of the local 
manifestations of waning vital energy ; but it may be promoted by 
any or all exhausting or depressing causes. No special or peculiar 
line of causation can be pointed out. 

Treatment. — This can be only conservative, not curative. Tonics, 
particularly iron, with generous diet, sea or mountain air, change of 



THYRO-CARDIAC DISORDER. 153 

scene, avoidance of anxiety and exertion, may do much to retard the 
degenerative process. Violent effort or emotional excitement may be 
suddenly fatal. Tranquil occupation only should be selected, and all 
rapid exercise, and even straining at stool, ought to be avoided. 

MODES OF SUDDEN DEATH IN HEART DISEASE. V 

We may briefly enumerate these as, 1. Arrest of the heart's action 
from debility of the muscular walls ; 2. Spasm of the ventricles ; 
3. Extreme obstruction, or regurgitation ; 4. Rupture ; 5. Heart- 
clot. Indirectly, cerebral or pulmonary apoplexy. 

ANGINA PECTORIS. \ 

Definition. — An irregularly paroxysmal disorder, characterized by 
sudden attacks of severe pain, extending from the heart along the left 
arm, with a sense of stricture in the chest, prostration, and alarm. 

Pathology and Causation. — This appears to be a symptomatic 
affection ; connected in most, if not in all cases, with organic disease 
of the heart ; especially ossification of the coronary arteries. Gout 
predisposes to or excites it, but probably not in the absence of heart- 
lesion. It occurs generally in old people ; most often in men. 

Prognosis and Duration. — The attack may last from a few minutes 
to an hour, or even a day. Commonly it is snort, going off with per- 
spiration or copious urination. A first attack may be fatal. Returns 
occur at variable intervals — days, weeks, or months ; each one gen- 
erally sooner and more violent, till one of them ends life. 

Treatment. — Stimulants and anodynes [F. 47, 48, 49] are indicated 
during the attack. Best will be Hoffmann's anodyne, laudanum, 
Warner's cordial, and brandy, in moderate doses, repeated in a short 
time if necessary ; with mustard plasters over the chest and between 
the shoulders, and the warm foot-bath. Where gout is present, colchi- 
cum [F. 45, 46] and alkalies are important. 

THYRO-CARDIAC DISORDER. V 

Synonym. — Ex-ophthalmic Goitre. 

Definition. — Enlargement of the thyroid gland in the neck, with 
over-action of the heart and cervical vessels, and prominence of the 
eyeballs. 

Nature. — This uncommon affection, of which I have seen but one 
case, is considered by Dr. Stokes to consist in a more or less perma- 
nent functional excitement of the heart ; which may produce finally 
dilatation and hypertrophy, with dilatation also of the jugular veins, 
and an aneurismal condition of the thyroid gland. Although consid- 
erable disturbance and prostration of the system must attend such a 
state of things, yet it has been repeatedly recovered from, as in the 
case which I saw. The cause of the affection has not been made out. 

Treatment. — Tranquillization of the heart is the main indication. 
Yeratrum viride, in doses not at all nauseating (two or three drops 
of the tincture every three or four hours), may be persevered in, while 



154 DISEASES OP ORGANS OF CIRCULATION. 

watching its effects. Other treatment must depend upon the general 
condition of each patient. Of course violent exercise and mental 
excitement must be avoided. 

/ 
PALPITATION, vj 

All excessive or consciously disturbed action of the heart is com- 
monly thus designated. Over-action, in particular, may have either 
of the following origins : — 

1. Nervous, or hysterical ; 2. Dyspeptic; 3. Rheumatic, or gouty; 
4. Hypertrophic. 

-Nervous palpitation occurs in anaemic persons, especially hysterical 
females, or in those otherwise debilitated. Alcoholic intemperance, 
strong coffee, tobacco, excessive venery or self-abuse may produce it. 

Dyspepsia is very often attended by palpitation, sympathetic with 
the gastric disturbance. It usually, in such a case, is worse after 
meals. 

Gouty and rheumatic palpitations are also common. Their nature 
will be made known by the presence of other signs of the controlling 
diathesis. 

All of the above forms of merely functional disturbance of the heart, 
and especially the purely nervous, may be known from hypertrophic 
overaction, or the conscious impulse of dilatation of the heart, by the 
fact that they are not increased by moderate exercise ; are often, in 
deed, much diminished thereby. When the heart is enlarged, especially 
with valvular change, active movement causes distress and dyspnoea, 
with great acceleration of the cardiac movement. In palpitation of 
all kinds, during the attack, it is generally not possible to lie with ease 
upon the left side ; and orthopnoea may occasionally occur, without 
organic disease. 

The treatment of palpitation must vary altogether according to its 
cause. If nervous, invigoration of the system and enrichment of the 
blood are most probably needed ; by iron and other tonics, and regimen. 
Dyspepsia will require appropriate treatment; as a part of which, 
exercise in the open air will not be counter-indicated at all by sympa- 
thetic palpitation. 

Functional overaction of the heart, without organic disease, is in 
itself not dangerous. It is alarming, however, to the patient, as well 
as a source of discomfort ; and may, if long sustained, bring on true 
enlargement of the heart. All causes, therefore, of such disturbance 
ought to be sedulously avoided in the interest of health. 

CARDIAC EXHAUSTION. \ 

In our general hospitals during the late war, under my own obser- 
vation as well as that of other practitioners, quite a number of cases 
of soldiers presented, who were rendered unfit for duty by heart- 
symptoms, and yet without signs of valvular or other organic disease. 
Careful investigation of these satisfied me that the condition was one 
of muscular exhaustion of the heart ; owing to hard marching with 
deficiency both of rest and food ; especially during McClellan's penin- 
sular campaign. Symptoms of this were, — constantly rather rapid 



ANEURISM OF THORACIC AORTA. 155 

though not strong pulse, with less than normal vigor of the impulse 
of the heart; — the acceleration increased greatly, with dyspnoea, upon 
even slight exertion. The sounds of the heart were not altered except 
ID the diminution of duration and force of the first sound, making it 
more like the second. After many months of rest, these men im- 
proved, so as to be likely to recover. No special treatment seemed 
to be required. 

ANEURISM OF THORACIC AORTA. V 

A bulging in the front of the chest, in which pulsation is felt, not 
continuous or identical with that of the heart, and over which reso- 
nance upon percussion is dull, — is probably an aneurismal tumor. If 
a thrill is also perceptible in it, with or without a murmur on ausculta- 
tion, we may be still more confident in the diagnosis ; and when the 
signs of pressure upon the air-tubes, oesophagus, sympathetic or re- 
current laryngeal nerve, or thoracic duct occur, it is nearly certain. 

Murmur may, however, be absent; so may thrill; the bulgiug may 
be slight, and the percussion resonance little altered. The sign of 
most consequence is, the existence of two points of pulsation in the 
chest, the cardiac and the aneurismal ; the latter coinciding almost 
with the diastole of the heart. 

The signs of pressure are, chiefly, pain, cough, dyspnoea, loss of 
voice, difficulty of swallowing; and (as 1 have seen in one instance) 
emaciation from obstruction of the thoracic duct. 

Cancerous or other tumors may produce all these latter signs ; but 
such tumors do not pulsate. In empyema the beat of the heart some- 
times impels the fluid so as to throb somewhat widely ; but this is 
still a single cardiac impulse. Occasionally a consolidated lung, in 
phthisis, may vibrate forcibly with the pulmonary artery ; but other 
signs then make clear the disease. 

The course of aortic aneurism is usually very gradual, — often lasting 
for a number of years. Death occurs — 1. from sudden rupture and 
copious hemorrhage ; 2. from slighter rupture and slow leakage ; 3. 
from slow exhaustion by pressure, interfering with respiration, deglu- 
tition, &c. 

The causation of thoracic aneurism is obscure. It occurs nearly 
always in rather elderly people, in whom the process of degeneration 
of the vessels has commenced ; but now and then it is met with before 
middle life. 

The following points may be added in regard to its clinical his- 
tory :— 

1. The effects of the aneurismal pressure may vary from time to 
time ; much more than they do in cancer. 

2. The aneurismal impulse may be even stronger than that of the 
heart; but a feeble impulse in some instances attends a large aneurism. 

3. Destruction of one or more vertebrae from absorption under 
pressure (as shown by autopsy) is not uncommon. 

4. Phthisis is often associated with aneurism of the aorta. 



156 DISEASES OF ORGANS OP DIGESTION. 



ABDOMINAL AORTIC ANEURISM. \ 

Of this, the signs and symptoms are — deep-seated severe pain 
(occasionally intermitting) in the back and abdomen, increased by 
certain movements ; unaccompanied by fever, but resisting all treat- 
ment ; later, muscular spasms of the lower limbs, displacement of the 
liver, and the manifestation of a pulsating abdominal tumor, felt upon 
palpation, over which there is dulness of resonance upon percussion. 
The higher up the aneurism, the more severe are the pains and other 
symptoms of disturbance. 

Aneurism of the aorta may, without careful examination, be con- 
founded with aortic 'pulsation without tumor (common in dyspepsia, 
&c), or with neuralgia, rheumatism of the bowels, colic, worms, disease 
of the liver, caries of the spine, psoas abscess, or cancer. Only the 
discovery of a distinctly pulsating tumor (not a tumor moved by 
subjacent pulsation) can establish the presence of aneurismal disease. 

The treatment of either thoracic or abdominal aortic aneurism is* > 
in a word, null. Hygienic measures may retard decline, and careful 
self-management may avert a sudden catastrophe ; that is all. Exertion 
and excitement must, of course, be prohibited altogether. 



AFFECTIONS OF THE ORGANS OF DIGESTION. 

STOMATITIS. 

Definition. — Inflammatory disease of the mouth. 

Varieties. — 1. Simple stomatitis. 2. Aphthae. 3. Thrush. 4. 
Inflamed ulcer or cancrum oris. 5. Gangrene of the mouth. 6. 
Mercurial sore mouth or salivation. 7. Nursing sore mouth. 8. Scor- 
butic disease of the mouth. 

Simple Stomatitis. — From taking very hot or corrosive liquids into 
the mouth, it may become inflamed; this condition being shown by 
redness, swelling, soreness and heat of the tongue, gums, lining mem- 
brane of the cheeks, palate, and fauces. Corrosives (as sulphuric acid 
or creasote) may whiten the mucous membrane superficially. 

The course of such an affection is generally simple and brief — re- 
covering in a few days under mild treatment. Glossitis, however, or 
inflammation of the tongue, may be more obstinate and serious. I 
have seen the tongue so swollen as to protrude from the mouth for 
more than a week, too large to return. 

Slight ulcerations and fissures often occur in simple stomatitis, in- 
creasing the soreness and pain ; and increase in the flow of saliva is 
common. 

Treatment. — In the beginning, holding ice, iced gum-water or flax- 
seed tea frequently in the mouth, or if a corrosive agent be the cause, 
almond oil or dilute glycerin [F. 50], will soothe the irritation. Jn 
violent glossitis, leeches may be applied to the swollen tongue ; even 
free incisions may be called for to relieve its swelling ; later, solution 
of alum (3ij in fgvj of water) or sulphate of zinc (gr. j in fgj) may be 
used as a wash. Remember that such articles ought not to remain 
long in contact with the teeth, the enamel of which they may impair. 



STOMATITIS. 157 

Follicular inflammation of the mouth is recognized by small red 
elevations over the tongue, soft palate, &c. This is common in infants 
during dentition ; as well as in adults of impaired general health. It 
requires no speciality of treatment. 

Aphthae. — These are small ulcers, with whitish surfaces, following 
a vesicular eruptive inflammation of the mouth. The vesicles are 
small, round or oval, of a pearly appearance, and contain serum. They 
break in a few days, leaving a sore white ulcer, with redness around it. 
They may be scattered or confluent. Fever may attend the latter, 
with disorder of the stomach. Though not common in the earliest 
infancy, children sometimes have this disease, but less often than 
adults. Decayed teuth may produce it. On the whole, it is to be 
considered rare. Its duration is generally a week or two, but confluent 
cases may last a month, and have occasionally been fatal. 

Treatment. — The constitutional condition may require cooling 
laxatives or saline diaphoretics, and gastric irritation may call for 
antacids, as bicarbonate of soda or magnesia. Chlorate of potassa 
should be given, 5 to 20 grains four times daily. Locally, at first, 
flaxseed tea or gum-water, or a solution of glycerin in rose-water, may 
be frequently applied. When ulceration occurs, a powder, consisting 
of equal parts of prepared chalk and pulverized gum arabic [F. 51], 
may be dusted or laid over each of the ulcers, several times a day. A 
wash of borax, myrrh [F. 52], alum, sulphate of zinc [F. 53], or ace- 
tate of lead, may also be applied. If the ulcers prove severe or obsti- 
nate, strong solutions of sulphate of zinc (15 grs. in fjj of water) or 
nitrate of silver (20 grs. in f'3j), or solid sulphate of copper, may be 
used to touch the ulcerated surface every day or two. 

Thrush; Muguet.— This is much most frequent in infancy. Its 
peculiarity is, the occurrence, after a day or two of diffused inflamma- 
tion, of a number of small whitish points within the mouth, which 
coalesce and form patches of a whitish curd-like exudation (often con- 
founded with aphthae). In bad cases it may become brownish. This 
may fall off and be renewed, more than once. The mouth is hot, the 
stomach disordered ; vomiting and diarrhoea may occur, with some 
fever. The attack lasts from one to two or three or more weeks ; 
being seldom dangerous except in children otherwise in poor health. 
It sometimes attacks adults. 

Nature. — The specific nature of the curd-like exudation appears to 
be connected with a microphytic (minute vegetative) growth, to which 
the name of oidium albicans has been given. 

Treatment. — Experience favors the internal administration of 
chlorate of potassa [F. 54] in all severe forms of sore mouth. In the 
absence of a rationale by which its special applications might be 
definable, I would employ it in thrush as well as in aphthae, <fcc. A 
child under five years of age may take from one to five grains of the 
chlorate, in solution, several times daily. As a laxative, magnesia 
will be suitable. Feeble cases may require quinine, beef-tea, brandy, 
and milk, in quantities proportioned to their condition and age. 

Locally, at first, we may use flaxseed or gum arabic emulsion, — 
then glycerin and rosewater (one part to four or five), borax in solu- 
tion (2 drachms in 4 ounces) or in powder, equal parts with sugar, — 
and later, tincture of myrrh in water (f^ss in 1 3 ij ) , alum solution, or 
14 



158 DISEASES OF ORGANS OP DIGESTION 

sulphate of zinc, or muriatic acid with honey and water (acid, muriat. 
£j, mellis vel syrupi fgj, aquae f§ i j ) ; the latter being applied carefully 
with a camel's hair pencil, occasionally. 

Cancrum Oris. — Canker of the mouth is characteristically ulcera- 
tive, from the commencement. It begins on the cheeks, gums, or 
lining of the lips ; but may reach the fauces. The ulcer is grayish or 
yellowish-white, with an inflamed border and environs ; the cheek may 
swell from it externally. It is quite painful. Saliva flows freely, and 
the odor of the breath is offensive. Fever is often present. The 
complaint may last for several weeks or even months ; but is almost 
never fatal. It is most common in children, from two to six years of 
age. 

Treatment. — Besides general measures, adapted to the condition of 
the 'patient, the same local applications, mentioned as appropriate in 
different forms of sore mouth, may be used. Direct touching of the 
nicer with a strong solution of sulphate of zinc (gr. xv vel xx in fgj), 
or with the solid blue stone (sulphate of copper) twice daily, will do 
the most for its cure ; especially with the intermediate " dressing" of 
powder of chalk and gum arabic, and occasional washing with glyce- 
rine and rose-water. 

Gangrsena Oris. — Extreme inflammation or ulceration, in the mouth 
as elsewhere, may end in gangrene ; but this affection is peculiar, and 
may be unconnected with any severe inflammation. A morbid state 
of the system seems to predispose to it. It occurs mostly in children, 
but has been met with in adults. 

There is, at first, an ash-colored ulcer, most often on the gums or 
inside of the cheek. If the latter, it is accompanied by swelling. 
Spreading, it assumes a sloughing character; the breath grows fetid ; 
acrid fluid is discharged, with copious salivation; other like ulcerations 
are formed, the bones of the face are affected with necrosis, and the 
teeth fall out. Penetrating the cheek, mortification may go on, 
rapidly, reaching sometimes even the ethmoid bone. Low fever and 
prostration attend these local changes ; later, diarrhoea, colliquative 
perspirations, and death. The only well-marked promotive causes of 
this very serious disease are, bad air (especially crowd-poison) and 
insufficiency of food. When treated early, it is often quite manage- 
able ; but after extensive sloughing has occurred, the prognosis is bad. 

Treatment. — Early, I should always try the chlorate of potassa. 
Quinine, and tincture of chloride of iron [F. 56] will be required on 
account of the tendency to prostration. Beef-tea and wine whey, or 
brandy or whisky punch, pro re nata, are called for, by the same 
indication. 

To the part, at first, the astringent lotions, mentioned already, may 
be applied. When the gangrenous condition becomes pronounced, a 
solution of liquor sodae chlorinat. in glycerin (fgj in fgij) may be 
applied frequently. Solution of creasote in glycerin, or in water 
(gtt. iij to gtt. xx in f^j) may meet the same purpose ; or permanga- 
nate of potassa (gr. x in fgj) ; or chloride of zinc (gr. j in fgj) ; or 
sulphite of soda (&j in fgj) ; or bromine (^ss in f^ij)- 

Mercurial Sore-Mouth. — Salivation is made known in its approach, 
by a " coppery" taste, soreness of the gums, tenderness of the teeth 
when pressed together, with redness and swelling of the gums, and a 



TONSILLITIS. 159 

broad white line just beyond their edge. The tongue also may swell. 
The flow of saliva increases greatly ; the cheeks and even throat may 
grow sore and painful ; the breath offensive. Ulceration of the gums 
takes place in severe cases, with loss of the teeth. Even sloughing 
may follow, approaching the state of things in gangrcena oris. Diffi- 
culty of swallowing may be so great as to threaten starvation ; and 
irritative fever may result from the local disorder. 

Treatment. — Moderate salivation will always pass away in a few 
days, spontaneously. A good mouth-wash for it is brandy and water, 
one part of the former to four of the latter ; alum may be added to it 
[F. 59], or a little tincture of myrrh. Ulcers or sloughs should be 
treated as in other varieties of stomatitis. 

Opium may be called for, at least at night (e. g. Dover's powder, 
10 grains at bedtime), by the distress of the system. Milk diet, or 
some other liquid nourishment, must be given during the difficulty of 
deglutition. In good practice, at the present day, no physician ever 
seriously salivates a patient. 

Nurses' Sore-mouth. — Women who suckle children, and sometimes 
those who are advanced in pregnancy, are liable to ulcerative stoma- 
titis. It begins with small, hard, painful swellings on the tongue and 
cheeks, which ulcerate, and are attended by a great deal of local, aud 
sometimes constitutional irritation. When the infant is weaned, the 
affection subsides soon. 

Treatment. — Chlorate of potassa has in this complaint a special 
curative power. 20 grains of it may be given three or four times 
daily. Iron, quinine, etc., may be required in subjects of obvious de- 
bility. Local treatment, such as has been given for cancrum oris, etc., 
will also have its utility. 

Scorbutic mouth affection will be dealt with in another part of the 
book, — under Scurvy. 

TONSILLITIS. 

When severe, this is commonly known as quinsy. Soreness of the 
throat in swallowing, with pain or swelling of one or both tonsils, and 
fever, are its symptoms. Unless relieved in a few days, the pain be- 
comes very constant and throbbing, dysphagia extreme, and when the 
patient begins to be seriously alarmed', a tonsillar abscess breaks, or 
is opened by the physician, and recovery soon follows. 

Treatment. — A dose of citrate or sulphate of magnesia, or other 
cooling aperient, should be given the first day. Then, wine of ipecac, 
twenty drops every three hours, with frequent draughts of flaxseed 
tea or flaxseed lemonade. If the swelling, heat, and pain of the throat 
are great, apply from 20 to 40 American leeches to it. Then, or in- 
stead in mild cases or feeble subjects, poultice with flaxseed meal to 
which lard and laudanum have been added; bathing, w T hen the poultice 
is changed, with liniment of ammonia, or soap liniment to which aqua 
ammonia has been added. If still severe, and not certainly suppurat- 
ing, a small blister may be applied, or the part may be painted with 
tincture of iodine. When an abscess is evidently forming, poultices 
will be better, until it is ready to open from within. 

Lancing the suppurated tonsil requires care, not to open the internal 



160 DISEASES OF ORGANS OF DIGESTION. 

carotid artery. The point of the lancet should be directed towards 
the middle, not the outside, of the throat. 

Not unfrequently, especially in children, repeated attacks of non- 
suppurating inflammation of the tonsils will leave them inconveniently 
enlarged. Sometimes persevering use of astringent gargles, or touch- 
ing daily with strong solution of tannin or nitrate of silver, will make 
them shrink to the normal size. If not, excision of a part of the tonsil 
may be proper. With Fahnestock's, or any other guillotining instru- 
ment, the operation is easy and safe ; at all events if it be not attempted 
to remove the whole gland, which is not necessary. 

PHARYNGITIS. 

Slight sore throat is among the commonest of affections, requiring 
for its treatment only mild gargles (as alum in flaxseed or sage tea), 
demulcents (flaxseed or gum arabic or slippery elm infusion), fomenta- 
tion with volatile liniment or spirits of turpentine, and a dose of a 
saline cathartic, with slop diet. With children who cannot gargle, 
finely powdered alum may be blown into the fauces and throat, 
through a quill, more readily than in any other way. 

Chronic pharyngitis is often a much more troublesome, though not 
dangerous local disorder. The mucous membrane becomes perma- 
nently hypersemic, almost granulated ; with either abnormal dryness 
or a thickened secretion ; and constant soreness. In the treatment 
of this, all the different astringent, demulcent and alterative appli- 
cations may be tried — sometimes without success. When nitrate of 
silver, tannin [F. 60], sulphuric and muriatic acids, sulphate of zinc 
and acetate of lead have been found to fail, it may happen that ice, 
or gargling often with ice- water, will prove more useful. 

Counter-irritation, with repeated small blisters, tincture of iodine, 
or croton oil, is always a suitable and important part of the treatment 
of chronic inflammation of the throat. 

Ulcerated Sore-throat. — This may be idiopathic, syphilitic, or 
tuberculous. The former is most uncommon. 

The treatment in the first variety consists of the local application 
of blue stone or, lightly touched, solid nitrate of silver to the ulcers 
if within reach. The syphilitic will require, also, iodide of potassium 
[F. 61 J internally (gr. v vel x ter die) ; the tuberculous, tonics, gene- 
rous diet, and cod-liver oil. 

RETROPHARYNGEAL ABSCESS. 

This most often follows fever as a sequela ; but is altogether rare. 
It is shown to the careful observer by dysphagia and dyspnoea, much 
increased by the recumbent posture ; yet not, as in croup, increasing 
from day to day, or disappearing in a short time. There is also stiff- 
ness of the neck, and swelling on one or both sides of it. In such cir- 
cumstances, a finger passed over the tongue into the pharynx may 
find a firm projecting tumor occupying its posterior and lateral walls. 
It may prove fatal, by asphyxia, or by preventing the patient from 
swallowing food. When diagnosticated in time, the matter may be 
let out by opening the abscess with a lancet, through the pharyngeal 
wall. 



GASTRITIS. 161 



SIRICTTJRE OF THE (ESOPHAGUS. 

This is uncommon. Its principal causes are, if structural, corro- 
sive poisons, swallowed ; or ulceration of the throat involving the 
cesophagus, and contracting upon cicatrization. Functional stricture 
may be spasmodic, as in hysteria. Dysphagia, not otherwise accounted 
for, and obviously low down in its seat, or the rejection of food partly 
swallowed, may lead to a suspicion of stricture ; and examination 
with a bougie will fix the diagnosis. For the structural affection, I 
know of no appropriate treatment except dilatation with bougies 
made for the purpose, applied for a short period, oiled, once or more 
daily. 

GASTRITIS. 

Simple gastritis, in an acute form, is very rare. I have met with 
but one case of it, in a woman who was kicked over the stomach by 
her husband. Corrosive poisons almost always involve the intestinal 
tube with the stomach. The most common form of " idiopathic" 
gastric inflammation is " gastro-hepatic catarrh," or "a bilious 
attack," in which the stomach, duodenum and liver are all somewhat 
involved. 

Signs of stomachic inflammation are, epigastric pain and tender- 
ness on pressure, rejection of all food and drink, jactitation, and 
fever ; the pulse however being kept down by the impression made 
upon the circulation by constant nausea. 

Post-mortem evidences of gastritis are — redness, browner or deeper 
and more livid than natural, and dotted, stellated or arborescent, 
rather than diffused; moreover, not confined to dependent parts; 
enlargement of bloodvessels; in acute cases, softening of the mucous 
membrane: in more lengthened ones, either softening or hardening 
and thickening ; abundance of thickened mucus ; rarely, coagulable 
lymph ; almost never, pus. 

Gastro-hepatic catarrh may follow any of the causes of indigestion, 
or exposure to cold and wet. There is nausea, or vomiting of greenish 
yellow fluid, generally not copious, but very acrid ; headache and 
dizziness ; constipation of the bowels, and fever. In the treatment of 
this, magnesia is a good quieting stomachic and cathartic ; many will 
be relieved as soon by a bottle of solution of citrate of magnesia. Ice, 
melted in the mouth and swallowed slowly, will be comfortable. Rest 
and abstinence from food as nearly as possible will, with the above, 
generally complete the cure in two or three, or not many more days. 

The best preventive or abortive of " bilious attacks" is blue pill, 
timely administered. Let the first nausea, constipation, and headache 
be met by giving at bedtime two or three grains of blue mass in pill 
(the u lang syne' 1 portion was from six to twenty), followed in the 
morning by a teaspoonful or two of Husband's magnesia. If the bowels 
are free, bicarbonate of soda (which is a mild cholagogue as well as 
antacid) will be better ; the eighth part of a teaspoonful at a dose. 

Sick headache is usually a modification of the above, in so far as 
the sympathetic cephalalgia is especially severe. In some persons it 

14* 



162 DISEASES OF ORGANS OF DIGESTION. 

is periodic. The treatment above mentioned will be adapted to a 
majority of cases of it. 

Acute softening of the stomach is described by a few French and 
other writers, as a rapidly prostrating and dangerous affection in 
children, sometimes epidemic. Its symptoms are said to be, at first, 
those of simple gastritis; then, with or without diarrhoea, great agita- 
tion, prostration, want of sleep, and insensibility, — and death in one 
or two weeks from exhaustion. I have never met with any such case ; 
although an irregular fever with gastric irritation (gastric fever or 
infantile remittent) once had a regular place in the nosological cata- 
logue among fevers. It appears to me to be scarcely uniform enough 
for so special a designation or consideration. 

CHRONIC GASTRITIS. 

While the same doubt as to the pathological correctness of the 
name (indicating inflammation) exists in the case of this disease as in 
other u chronic inflammations" (see General Pathology), an affection 
of some distinctness of character, commonly called by the above title, 
is often observed. With the greatest brevity, we may indicate its 
symptomatology by contrasting it with that of atonic dyspepsia. 

In Chronic Gastritis. In Atonic Dyspepsia. 

Much epigastric tenderness. Little or no epigastric tenderness. 

Pain increased by active exercise Pain not increased by exercise, 

or stimulating food. lessened by stimulating food. 

Vomiting usually. Vomiting rarely. 

Eructation of gas rarely. Eructation of gas commonly. 

Chronic gastritis is apt to be obstinate but not dangerous to life. 

Treatment. — Counter-irritation over the epigastrium, by repeated 
vesication, will be useful. Internally, nitrate of silver [F. 62] , iu pill, 
beginning with gr. \, with gr. ^ of opium, and increasing in a few days 
or a week, gradually rising to 1 gr. thrice daily, with proportionate 
quantity of opium, I believe, upon experience, to be the most valuable 
medicine. Sub-nitrate of bismuth [F. 63] is for the same condition 
lauded by some. Most important is a bland diet ; lime-water and 
milk, arrowroot, tapioca, sago, jellies, cracker soaked in ice-water, etc., 
in small quantities at short intervals. Ice will often quench thirst to 
better advantage, without disturbing the stomach, than water. 

ANTI-EMETIC REMEDIES. 

Vomiting is so frequent and troublesome a symptom, in many dis- 
eases besides inflammation of the stomach, as to demand much practical 
study from the physician. For this reason, though quite in deviation 
from systematic routine, I here introduce an enumeration of the most 
available medicines used for the relief of the symptom of vomiting — 
the selection among them depending upon the judgment of the practi- 
tioner as to the real cause of that symptom. At the same time it is 
clear that many of these remedies prove useful for vomiting when 
produced by very different and almost opposite causes ; the symptoms, 



ULCER OF THE STOMACH. 



163 



as such, rationally demanding medication when uncertain or in search 
of its cause. 



Ice. 

Lime-water. 

Mineral water. 

Effervescing draught. 

Champagne. 

Brandy. 

Paregoric. 

Solution of morphia. 

Aromatic spirit of ammonia. 

Comp. tinct. of cardamom. 

Comp. sp. of lavender. 

Bicarbonate of potassa. 

Bicarbonate of soda. 

Magnesia. 

Camphor. 

Calomel, small doses. 

Blue pill. 

Creasote. 



Cinnamon water. 

Infusion of cloves. 

Hydrocyanic acid. 

Aconite. 

Chloroform. 

Nitrate of silver. 

Oxide of silver. 

Subnitrate of bismuth. 

Oxalate of cerium. 

Enema of laudanum. 

Spice poultice. 

Sinapism. 

Blister over epigastrium, vesi- 
cated surface being dressed 
with acetate of morphia (gr. ij, 
with gum-acaciae. gr. x). 

Hypodermic injection of morphia. 



[See F. 64, 65, 66, 67, 68, 69, 70.] 



ULCER OF THE STOMACH. 

This serious affection is rare after the middle of life. It is most 
often met with in feeble systems, especially in women. 

Symptoms. — Dull, sickening pain in the stomach, extending to the 
back, with localized tenderness on pressure. The pain is increased by 
motion, and by food, especially by hot food, or by sugar. Vomiting 
occurs, not copious, but rather frequent. Yomiting of blood is an 
important sign ; it is impossible to be certain of the existence of an 
ulcer in the stomach without it. The amount of blood thrown up at 
once may be very small. 

It is often difficult to diagnosticate gastric ulcer from chronic gas- 
tritis, as well as from cancer, caries of the spine, and aortic aneurism. 
No hsematemesis, however, is met with in the first, third, and last ; 
and a tumor, at some period, will make known cancer. So will angu- 
lar deformity demonstrate spinal caries. 

Perforation, causing peritonitis, and copious hemorrhage, are the 
most dangerous terminations of gastric ulcer. The signs of the former 
are, abdominal swelling and diffused pain, with collapse. 

Treatment. — Bland diet is very important. Arrowroot, tapioca, 
sago, corn-starch, rice, and lime-water and milk are suitable. Beef or 
mutton tea (concentrated) will be better for the feeble than solid food. 

Nitrate of silver, in pill with opium [F. 62] ; oxide of silver, in 1 or 
2 grain doses ; and subnitrate of bismuth, are given with the hope of 
promoting cicatrization of the ulcer. Opium alone, in pill, or lauda- 
num, &c, or conium or belladonna, as anodynes when the pain is severe. 
When hemorrhage is threatening, creasote (i drop to 2 drops), tanuin, 
acetate of lead, oil of turpentine (small doses), ammonio-ferric alum. 
Hypodermic injection of morphia has been used with advantage. 



164 DISEASES OF ORGANS OF DIGESTION. 

CANCER OF THE STOMACH. 

Scirrhus of the pylorus is the most common form ; occasionally the 
cardiac orifice is the seat of cancer. The usual symptoms are pain, 
in rare instances absent or nearly so, often excruciating ; epigastric 
tenderness, about in proportion to the pain ; vomiting, of food, mucus, 
and " coffee-grounds," or mixed blood and mucus, almost never pure 
blood ; acidity and other symptoms of indigestion ; fetid breath ; de- 
cided constipation ; emaciation, and cachectic, almost jaundiced, sal- 
lowness of complexion ; sometimes irritative fever. The diagnosis is 
made nearly certain by the discovery of a tumor ; not absolutely so, — 
as the tumor may be fibroid, and not malignant. 

Cancer of the stomach seldom occurs before forty years of age. Its 
duration averages about a year ; it seldom reaches two years. The 
patient commonly dies by a slow starvation, the stomach becoming 
incapable of digesting and transmitting food. 

No treatment can avail for the cure of such an affection. To nourish 
by concentrated articles of diet, as beef-tea, milk, &c, and to allay 
suffering by judicious use of anodynes, will be all that we can do. It 
is a frequent form of cancer ; as of 9118 cases of cancer in Paris in 
four years, 2303 affected the stomach. 

Cancer of the Duodenum, Ccecum, Rectum, and Omentum are much 
more rarely met with. Their possibility must always be remembered 
in considering the diagnosis of abdominal tumors. 

DYSPEPSIA. 

Although denied a special place in nosology by writers upon diag- 
nosis, clinical experience calls for a separate recognition of this as a 
disease, complex as its pathology is, and diverse as may be its symp- 
toms. Of the latter, only a very general account can be given. 

Symptoms. — The patient feels his stomach all the time, though not 
nearly always with pain. When the latter occurs, it is often in the 
breast, causing suspicion of pectoral disease. Little or no tenderness 
on pressure exists, nor is there much nausea, nor vomiting. The 
mouth is clammy, or has a sour or bitter taste. The complexion is 
sallow. The bowels are costive, and stools deficient in color. Other 
frequent symptomatic affections are cardialgia (heartburn), pyrosis 
(waterbrash), hypochondriasis, palpitation of the heart, headache, and 
disorders of the senses, as diplopia (seeing double), &c. Dyspepsia is 
not a dangerous, but is frequently a very obstinate disease. 

Pathology. — The functional disturbances above enumerated have 
their seat, more or less prominently, in different parts of the digestive 
apparatus ; in the alimentary mucous membrane, glandular organs, or 
muscular, or ganglio-nervous. The distressing gastro-intestinal irri- 
tation, cardialgia, pyrosis, &c, are located in the mucous membrane. 
Defective action of the liver and enteric glands produces constipation, 
with its consequences; imperfect secretion of the gastric juice, and 
pancreatic secretion, like hepatic inaction, impairs the whole process 
of digestion. So does atony of the muscular coat of the stomach ; 
while deficient power of the peristaltic intestinal contraction is per- 
haps the most common cause of constipation. Insufficient or perverted 



DYSPEPSIA. 165 

innervation may originate or intensify any or all of these morbid states 
and actions. Sometimes this is so obviously primary and predominant, 
as to justify the use of the terra, in certain cases, of ''nervous dys- 
pepsia." 

Causation, — Most briefly, we may assert the causes of dyspepsia to 
be, either one or several of the following : too much food, or too little 
food ; imperfect mastication, and hurry in eating; too little exercise; 
too much fatigue ; excessive study, or emotion of mind ; inordinate 
use of ardent spirits, opium, tobacco, coffee ; or of medicine out of 
place. 

Treatment. — This involves regimen, as well as medication : the 
first is most important. The meals should be regular, and with suffi- 
cient time allowed ; and all the food should be simple as well as 
nutritious; variety being obtained rather by having a change from 
day to day. than by a number of dishes at each meal. Some dyspeptics 
are obliged to eschew variety, and confine themselves to a routine of 
beef, mutton, and stale bread. Caution should be used not to blame, 
unjustly, particular articles as " disagreeing," when everything disa- 
grees, because of the state of the stomach. But a sensible person 
will be able mostly to ascertain what things agree best with his diges- 
tion ; and others should not be taken. 

Most persons even of feeble digestion can eat beef, mutton, chicken, 
turkey, oysters (not fried nor raw, but roast, panned, stewed or 
steamed); with stale bread, bran occasionally, as more laxative; 
crackers, boiled rice, tomatoes, and young and tender beets. When 
weak enough to require any stimulant, sherry or Madeira wine, or ale, 
or in the feeblest, brandy, will agree best at dinner. Let Dr. X. 
Chapman's precept be here remembered, " whatever we grant, let it be 
sparingly " Advise, for example, half a wineglassful of Madeira or 
sherry, or half a tumblerful of ale, or one or two teaspoon/ids of 
brandy or whisky, at or after dinner. For breakfast and supper, tea 
will be the best drink for refreshment ; milk for nourishment ; although 
some persons do not digest milk with ease. Coffee I have so often 
known to produce dyspepsia, that I would forbid it altogether; not- 
withstanding its toleration by some highly respectable authorities. 
Cocoa is too rich for most dyspeptic stomachs; some find it accept- 
able. Fruit, especially when fresh, as a general rule is useful ; peaches, 
in season, are so with few exceptions. Stewed fruit is also excellent 
for laxative effect. Preserves, cakes, and pies, must be avoided. If 
a full meal cannot be taken without discomfort, it will be better to 
appease hunger or sustain strength by a small and simple " bite" 
between meals. Idleness and emptiness, as well as repletion, in the 
stomach, promote disorder. 

Exercise, daily, in the open air, is very important to the dyspeptic. 
So is bathing, to maintain healthy action of the skin, with which the 
stomach sympathizes. But active exercise ought not to be taken 
just before or just after a meal. " After dinner sit awhile." 

Mental states, and nervous impressions, are also of great conse- 
quence. Anxious occupation, or harassing responsibility, may in- 
crease greatly the difficulty of recovery. Thus travelling, or resort- 
ing to watering places, with release from care, may assist the cure. 



166 DISEASES OF ORGANS OF DIGESTION. 

The medical treatment of dyspepsia involves a number of indica- 
tions, not always exactly the same. Especially are tonics, laxatives, 
antacids and other palliatives, and alteratives, apt to be required. 

Tonics. — Pure vegetable bitters, as gentian [F. 72, 73], quassia, 
and columbo, are most suitable as direct stomachics. Chiretta is a 
favorite with some. Oxide of silver has had one or two enthusiastic 
advocates. Where nervous debility is prominent and particularly in 
cases of long-standing, extract of nux vomica [F. 71], or strychnia 
in very small doses (one-fortieth to one-thirtieth of a grain) will often 
do much more good than any other medicine. Iodide of iron, in 
anaemic cases, may be given. 

Laxatives. — Rhubarb has been, time out of mind, the stand-by, for 
habitual constipation [F. 75, 76, 77]. If it be insufficient alone, or 
lose its effect, compound extract of colocynth, aloes, or resina podo- 
phylli may be added, in pill. Senna, magnesia, and sulphur may be 
used occasionally, for special indications. Saratoga, Cheltenham, and 
Vichy waters are found sometimes to have excellent regulating effects. 

Antacids. — After meals, a pinch of bicarbonate of soda (gr. v to 
gr. x) or half as much bicarbonate of potassa, or a dessert-spoonful 
of lime-water, will, in case of acidity, contribute much to the comfort 
of the patient. Carbonate of magnesia and aromatic spirit of ammonia 
are preferred by some; and charcoal has useful absorbent powers. 
Sulphite and hyposulphite of lime or soda, for antiseptic effect, may 
also be given to allay the after symptoms of indigestion. 

Alteratives. — In the commencement of the treatment of a case of 
dyspepsia, in which derangement, and commonly inaction, of the liver 
is most generally present, experience justifies the moderate use of blue 
pill. I prefer to give it in fractional doses, in such a case, say gr. \ 
thrice daily for a week [F. 74]. Occasionally it may require to be 
repeated, at intervals ; but should never be pushed to salivation. Nitro- 
muriatic acid, in 3 or 4 drop doses, acts as a mild tonic both to the 
stomach and the liver ; and may well follow blue mass, where hepatic 
torpor is believed to exist. The same indication may be met, although 
with less certainty, by taraxacum. Nitric acid (2 or 3 drop doses) is 
highly lauded as a tonic by some practitioners. 1 

Cardialgia seems to depend mainly upon acidity, aggravated per- 
haps by the butyric fermentation. Aromatic spirit of ammonia, tinc- 
ture of ginger, and camphor water, as well as the antacids above 
named, may be given for it; or chloroform, in 5 or 10 drop doses 
[F. 78]. 

Gastrodynia is a technical name for stomach-ache, common in 
dyspeptics. Carminatives are appropriate for it ; one of the best of 
these is oil of cajuput, 4 drops at a dose, on a lump of sugar. Spirits 
of camphor, compound spirits of lavender, compound tincture of 
cardamom, and essence of ginger are among the most popular prepa- 
rations for its relief. A mouthful of very hot water will sometimes 
quell the pain. 

1 Dr. Chambers, of London, speaks well of " Boudault's pepsin" obtained 
from the sheep's stomach. I do not know of any reliable equivalent for it in 
this country. Dr. Pavy, of London, states that a large part of Boudault's 
pepsin is inert. 



CONSTIPATION OF THE BOWELS. 



1G7 



Pyrosis is best treated by mild astringents ; as oil of amber, catechu, 
krameria, ammonio-ferric alum [F. 80], creasote (£ drop or \ drop 
doses) [F. 81], tincture of chloride of iron. 

After all, the dyspeptic may be able to do the most for his own cure. 
Jn the words of the late Prof. N. Chapman, "If he be intemperate, he 
is to become sober ; if he use opium or tobacco, he must relinquish it ; 
if indolent, he must be awakened to enterprise ; if luxurious, he must 
consent to change his scheme of life : if studious, to abandon the 
midnight lamp ; if afflicted, w r e must cheer him with the light of hope; 
or, if this be difficult, give him the great consolation of occupation, 
interest, employment." 

The following table is, with slight modification, from LeaYed : — 



EAST OF DIGEsT10>\ 

Mutton 

Venison 

Hare 

Sweet-bread 

Young pigeon 

Partridge 

Pheasant 

Grouse 

Beef-tea 

Mutton broth 

Milk 

Whiting 

Turbot 

Haddock 

Flounder 

Sole 

Fresh fish generally 

Roasted oysters 

Stale bread 

Rice 

Tapioca 

Sago 

Arrowroot 

Asparagus 

Seakale 

French beans 

Cauliflower 

Raked apples 

Oranges 

Grapes 

Strawberries 

Peaches 

Toast water 

Rlack tea 

Sherry 

Claret. 



MODERATELY DIGESTIBLE. 

Beef 

Lnmb 

Rabbit 

Turkey 

Duck 

Wild waterfowl 

Woodcock 

Snipe 

Soups 

Eggs, not hard boiled 

Butter 

Turtle 

Cod 

Pike 

Trout 

Raw or stewed oysters 

Potatoes 

Beets 

Turnips 

Cabbage 

Spinach 

Artichoke 

Lettuce 

Celery 

Apples 

Apricots 

Currants 

Raspberries 

Bread 

Farinaceous puddings 

Jelly 

Marmalade 

Rhubarb plant 

Cooked fruits 

Cocoa 

Coffee 

Malt drinks 

Port wine. 



HARD TO DIGEST. 

Pork 

Teal 

Goose 

Liver 

Heart 

Brain 

Salt meat 

Sausage 

Hashes and stews 

Mackerel 

Eels 

Salmon 

Herring 

Halibut 

Salt fish 

Lobster 

Crabs 

Shrimps 

Mussels 

Oil 

Melted butter 

Hard boiled eggs 

Cheese 

Fresh bread 

Muffins 

Buttered toast 

Pastry 

Cakes 

Custards 

Nuts, pears, plums 

Cherries, dried fruits 

Cucumbers, onions 

Carrots, parsnips 

Peas, beans, mushrooms 

Pickles 

Chocolate 

Champagne 

Cordials. 



CONSTIPATION OF THE BOWELS. 

There is no more frequent source of bodily discomfort than this ; 
and it may produce or increase the tendency to disease. The princi- 
pal causes of constipation are, — neglect of timely attendance upon 



168 DISEASES OF ORGANS OP DIGESTION. 

the call of nature ; want of exercise ; excess of mental strain ; and all 
the causes of dyspepsia, of which it is an almost constant part. Or- 
ganic obstructions may also, of course, give rise to it ; — as stricture, 
or cancer, or other disease of the large intestine, or a tumor so 
situated as to press upon the rectum ; or pregnancy. The most re- 
markable instances of constipation I have met with, in the absence of 
mechanical obstruction, have been in sea-sickness. 1 

Effects of inaction or non-evacuation of the bowels may be, enteric 
irritation, or even inflammation ; when much prolonged, dangerous 
intestinal obstruction ; in other instances, diarrhoea ; sympathetic 
headache, stomach, or liver disorder ; urino-genital irritation ; offen- 
sive perspiration ; and contamination of the blood, by the retention 
of excretory matter which the bowels ought to remove. 

Pathologically, costiveness may depend either upon muscular tor- 
por of the intestinal canal, or defective glandular secretion, or both. 

The treatment of constipation involves management as well as 
medicine. It is well to have a regular time to endeavor to empty the 
rectum. Straining is not beneficial, as it endangers piles or prolapsus 
ani ; but the act of defecation may be facilitated by kneading the lower 
half of the abdomen with the hands, so as to increase and aid peris- 
taltic contraction. 

In diet, fresh and stewed fruits are the best natural laxatives. 
Prunes are especially opening. Bran bread, by the mechanical 
quality of the particles, is somewhat of a peristaltic persuader. Mo- 
lasses occasionally will do, but it is too acescent to be taken con- 
stantly. 

Of medicines, pills of rhubarb and castile soap, one and a half grains 
each, may come first ; afterwards podophyllin [F. 82], colocynth, aloes, 
&c, if needed for especial torpor. An occasional dose of senna infu- 
sion may give a good start to the bowels. Better than to take medi 
cine every day or two, will be the use sometimes of enemata. An in- 
jection of warm water alone may answer at first. Then white soap, 
and afterwards brown soap may be added ; salt and molasses, sweet 
oil or castor oil when the former fail. A suppository of soap [F. 83] 
is less disagreeable to some persons, and will generally act. 

Where the torpor of the rectum approaches a paralytic state of 
the muscular coat, nux vomica will be very important [F. 84, 85]. 
The addition of belladonna to laxative pills is a not uncommon prac- 
tice. Electricity may assist in relieving the same condition. 

ENTERITIS. 

Definition. — Inflammation of the bowels. 

Symptoms.— Pain in a portion of the abdomen, increased by motion 
or pressure ; constipation ; fever. Later, abdominal swelling, vomiting, 
and mucous, sanguinolent or even purulent diarrhoea, in bad cases. 

Causes. — Blows or other injuries ; neglected constipation ; exposure 
to cold and wet. Corrosive poisons, as arsenic, &c. also cause enteric 

1 I have, when at sea, passed seven days without any inclination for a move- 
ment; and a gentleman told me that he had been eleven days without an 
evacuation, during a voyage. 






PERITONITIS. 169 

inflammation ; and it is a part of the results of strangulated hernia or 
other intestinal obstruction. 

Treatment. — A decidedly open and active case may require or bear 
early venesection in the robust. Leeching should be the rule; and it 
may be free. After that, poultices, of flaxseed meal or Indian mush, 
covered with oiled silk to retain moisture. Soft food alone can be 
taken, as arrowroot, oat-meal gruel, &c, or. in the weak, beef-tea. 
No medicine can do any good, unless it be opium in moderate doses, 
to relieve severe pain and promote rest. Cathartics are to be 
avoided, and entire stillness of the body in bed must be maintained. 
From slight or moderate inflammation of the bowels recovery may be 
confidently expected, with care; but aggravated cases of it are fre- 
quently fatal. 

Typhlitis is inflammation of the caecum or caput coli. It is rather 
more common than other forms of enteritis, especially after neglected 
constipation. Peri-typhlitis is a more obscure affection, differing, it 
seems to me, in involving a local or circumscribed peritoneal inflam- 
mation with typhlitis. Pain, tenderness, swelling and dull resonance 
on percussion, in the right iliac fossa, with constipation, are the 
symptoms. A number of cases which I have seen have all recovered. 
With more especial propriety than in most other cases of enteritis, 
opening the bowels by enemata at least, and even by a mild laxative, 
as castor oil, has seemed to be indicated. Kest, leeching, poulticing 
and soft diet, are the other main parts of the treatment. 

Abscess may occur notwithstanding; with safe issue if it open out- 
wardly — but fatal if it rupture into the peritoneal cavity. 

PERITONITIS. 

Inflammation of the peritoneum is one of the most dangerous of the 
phlegmasia^, because of the extent and important connections of the 
membrane involved. 

Varieties. — Simple or idiopathic ; accidental or traumatic ; tuber- 
cular ; puerperal. 

Causes. — Exposure to cold and wet; falls, blows, wounds, or other 
injuries; abscess of the liver; opening of aneurism, or perforation of 
gastric or intestinal ulcer (as in typhoid fever) ; tuberculization ; the 
puerperal state. 

Symptoms. — Diffused abdominal pain and tenderness, increased 
greatly even by slight movements, as breathing deeply or raising the 
lower limbs in bed ; vomiting ; constipation ; tympanites ; fever, with 
very rapid, though not full pulse. Later, that is in three or four 
days, in violent cases, delirium, insomnia, collapse. Its course is usu- 
ally rapid ; from the incipient chill to the fatal end, often occupying 
less than a week, though sometimes two. Simple sporadic perito- 
nitis, however, even in puerperal women, is, with careful treatment, 
much more often recovered from than not. 

Diagnosis. — The most important point is the discrimination of 
" simple peritonitis or metro-peritonitis in the puerperal state" from 
puerperal fever. The main difficulty about this is that the latter dis- 
ease includes peritonitis almost as constantly as erysipelas does dif- 
15 






110 DISEASES OF ORGANS OF DIGESTION. 

fusive inflammation of the skin. We can best discuss this differential 
diagnosis after considering the fever in question (See Puerperal Fever.) 

Morbid Anatomy. — After death from peritonitis, the swollen ab- 
domen is found nearly always to contain fluid, often considerable in 
amount, serous, sero-sanguinolent, sero-purulent, or pus. The latter 
may form in a very few days ; some facts have made it probable, even 
within forty-eight hours. Adhesions are present, with bands and false 
membranes of coagulable lymph, in various parts of the abdominal 
cavity ; and redness, thickening, and opacity exist to a greater extent. 

Treatment. — No disease requires or bears better the early use of 
the lancet than acute peritonitis. One free bleeding may sometimes, 
as it were, arrest the conflagration. Yet, apart from epidemic puer- 
peral fever, in which bleeding has upon the amplest trial, proved 
rather destructive than curative, there are cases in which economy of 
material makes venesection unsafe. Then leeching may be resorted 
to, in all but the very feeble subjects. Fifty or a hundred American 
leeches may be borne upon the abdomen by a patient who would faint 
if the same amount of blood were rapidly taken from a vein. Expo- 
sure of the body, during leeching, may be, with care, avoided. Poul- 
ticing with flaxseed or Indian meal should follow the leeching; the 
poultices should be large, but light, and covered with oiled silk, or 
changed very frequently to maintain warmth. If no leeches have been 
used, flannel dipped in spirits of turpentine may be put all over the 
belly. Later, if the case threaten obstinacy, a large blister should be 
applied. 

Of medicines, opium has now the almost universal confidence of 
practitioners. Except emptying the rectum at first, by mild enemata, 
no agitation of the bowels by medicine is to be encouraged. Calomel, 
as an antiplastzc, has been long valued by physicians of sagacity and 
experience. Though unable to prove that it does lessen the tendency 
to the effusion of coagulable lymph, I bow to the rational empiricism 
which, not hastily, raised it to the position of reliance for that end. I 
am not satisfied that its utility as an antiphlogistic, especially in severe 
inflammations, has been disproved. 

"With opium, then, I would, in peritonitis, give calomel : \ grain to 
1 grain of the former, with as much or less of the latter, every 2, 3, or 
4 hours, according to the severity of the pain and the urgency of the 
case [F. 86, 87]. When the stage of debility comes on, — or in very 
feeble cases from the first, — quinine, instead of calomel, may be com- 
bined with opium ; and support with beef-tea, and wine, brandy, or 
whisky, may be required. 

When peritonitis follows an injury, the treatment may necessarily 
have to be modified by the concomitant states of other organs involved, 
or by the general shock of the system. So, also, when perforation of 
an ulcer of the stomach or bowel, or the rupture of a hepatic or other 
abscess or aneurism, brings it on, — collapse is apt to occur speedily, 
forbidding any but anodyne and supporting treatment, and affording 
very little hope under that. Such cases are almost invariably fatal. 

Chronic peritonitis is sometimes met with. When not tuberculous, 
although a very serious affection, it may be recovered from ; the tuber- 
culous form, not with any more probability than would be pulmonary 
phthisis. 



COLIC. in 

Chronic peritonitis should be treated by rest in the recumbent pos- 
ture (in tedious cases the patient may be carried out into the sunshine 
and air), and resolvent and counter-irritant local applications; as re- 
peated blisters, tincture of iodine, mercurial ointment, cerate of car- 
bonate of lead. The latter, as a local sedative, I have found to have 
remarkable power. It may be prepared by adding gij of carbonate of 
lead to gj of fresh simple cerate [F. 88]. 

COLIC. 

Varieties. — 1. Flatulent. 2. Bilious. 3. Spasmodic, gouty or 
rheumatic. 4. Lead colic. Some writers also speak of nephritic 
colic ; the pain of which is chiefly owing to the passage of small cal- 
culi from the kidney to the ureter; while neuralgia of the bowels may 
also cause pain of similar seat to colic. Uterine colic, in females, may 
be either neuralgic, spasmodic, or obstructive (dvsmenorrhoea). 

Flatulent Colic. — This is caused by indigestion : as, from excess in 
the amount, or error in the quality of food ; or, from cold and wet, 
arresting perspiration and disturbing the balance of the "aqueous vis- 
ceral circulation," which is indispensable to normal digestion. Acrid 
irritation and gaseous distension produce irregular tonic or spasmodic 
contractions in the intestines ; principally in the colon. They are not 
confined to this, however. In a woman with irreducible umbilical 
hernia, I have, during an attack of colic, felt a portion of small intes- 
tine, several inches in length, grow rigid during the access of pain, and 
relax when it was relieved. Sometimes the stomach itself is the seat 
of pain. 

In flatulent or crapulent colic the abdomen is distended, but not 
very tender, except after long continuance of the attack. There is 
constipation of the bowels ; often nausea, with belching of wind, some- 
times vomiting; no fever. A sign of the yielding of the attack is 
audible or palpable rumbling of wind in the bowels ; showing a return 
of the almost arrested peristaltic motion. 

Bilious Colic. — The onset in this form is slower. Nausea is greater, 
and vomiting, of greenish or yellowish (biliary) fluid, is nearly constant. 
The pain may last, with very slight remission, for a number of days. 
The bowels are constipated. There may be considerable fever, and 
some tenderness of the abdomen on pressure. Meteorism is generally 
present ; but less in proportion to the pain than in flatulent colic. In 
protracted cases, slight or moderate jaundice is quite common. 

The greatest suffering in cases of bilious colic is attendant upon the 
passage of gall-stones from the gall-bladder to the duodenum. Then, 
the pain is chiefly in the right hypochondriac and lower part of the 
epigastric region; and sudden relief follows the escape of the calculus 
from the ductus choledochus into the intestinal canal. In other cases, 
we suppose that the irritant which gives rise to spasmodic pain is acrid, 
unhealthy bile ; which escapes into the intestines* and also, through 
the pylorus, into the stomach. 

Certain persons are particularly liable to such attacks; a large ma- 
jority of people, indeed, are never subject to them. I have known, in 
a number of instances, the same patient to have severe bilious colic 
once in every two or three weeks ; in others, the interval may be of 



172 DISEASES OF ORGANS OF DIGESTION. 

months or years. In one case, under my care, the attack was fatal. 
Autopsy then showed rupture of the gall-duct, under distension from 
obstruction by an impacted calculus. This must be very unusual. 
But prolonged bilious colic is never quite free from danger of inflam- 
mation of the bowels, or, in feeble persons, exhaustion from continued 
suffering and inanition. 

Gouty Spasmodic Colic. — In the " gouty diathesis," this is one mode 
in which the disease may invade internal organs. The stomach is the 
most frequent and dangerous seat of it ; the attack being commonly 
called "cramp in the stomach." It is characterized by suddenness, 
extreme severity of pain, and tendency to coldness and general pros- 
tration of the system. Repulsion of gout from the foot, as by cold 
applications, may bring it on. 

Lead. Colic; Painter's Colic; Colica Pictonum. — This disease has 
long been known as the result of exposure to the poisonous influence 
of lead. The name of " dry belly-ache" has also been applied to it. 
The abdomen is shrunken and rather hard; sometimes knots of con- 
tracted intestine may be felt. There is no tenderness, the pain being 
lessened or relieved by pressure. The suffering is often extreme, with 
restlessness ; the face and body being thrown into grotesque contor- 
tions. Constipation is obstinate ; the feces, when passed, small, dry, 
and hard. No fever exists. There is a blue line along the edge of 
the gums. Lead palsy may attend or follow the colic. 

Treatment. — In all forms of colic, the indications in common are, 
1, to open the bowels; 2, to relieve pain and spasm; 3, to prevent 
inflammation ; 4, to prevent future attacks. 

In flatulent colic, we should ascertain if the stomach has just been 
overloaded, or any very unwholesome food has been taken. If so, a 
prompt emetic will be proper ; as, a teaspoonful of mustard, or a table- 
spoonful of salt, in a teacupful of warm water — repeated in ten 
minutes if necessary. Then the antacid laxative, magnesia, may be 
given ; a teaspoonful, with ten to twenty drops of essence of ginger, 
or ten drops of essence of peppermint, five or six drops of oil of caje- 
put, or some other aromatic in corresponding proportion [F. 89]. If 
the bowels are not opened, or relief of the pain not obtained, no great 
length of time must elapse without an enema, of castor oil, salt, and 
molasses, or soap, in warm water. 

Should the stomach be much unsettled, and the pain violent, we 
may depend upon the immediate use of an injection to open the bowels ; 
and may give by the mouth antacids and carminatives. Thus, aro- 
matic spirit of ammonia, spirits of camphor, compound spirit of 
lavender, or oil of cajeput may be given, with bicarbonate of soda 
[F. 90] . Small doses every few minutes will be better retained than 
large ones at long intervals, and will act better. 

Anodynes come next in order. Extreme and sudden cases of colic 
belonging rather to the spasmodic variety require them at once. 
Other cases, the majority, are better managed by commencing with 
more corrective remedies, as above mentioned. When relief is not 
obtained without, we must give opium, chloroform, ether, or Hoff- 
mann's anodyne [F. 91]. The first is of all the most certain, although 
chloroform, internally used, in \ drachm to £ drachm doses, has not 



COLIC. 173 

disappointed me. Paregoric is a very good opiate for the same pur- 
pose. Pills of opium (especially old pills) may do better sometimes, 
where as much as a grain at once may be needed for severe pain. The 
" chloroform paregoric" [F. 92, 93] combines several good antispas- 
modics conveniently. Laudanum is the oldest stand-by, and well de- 
serves its place. 1 

It is remarkable how much opium a sufferer with great pain will 
sometimes bear without narcotism. I have known a teaspoonful of 
laudanum to be taken at once ; not even drowsiness following it. But 
care must be taken not to overdo this, or to give any more than is 
really necessary; or, the remedy may possibly prove worse than the 
disease. 

An important part of the treatment of colic is the use of warm 
external applications. Mustard should come first; a large sinapism, 
half and half with flour (if the mustard be of good strength) and 
covered with gauze or thin muslin, over the abdomen. When it is 
removed, after making a decided impression, let a little lard, sweet oil, 
or cold cream be rubbed on to prevent further irritation of the skin. 
A concentrated liquid preparation of mustard has lately been in use. 
Then, apply a hot flannel, dry, or wrung out of hot whisky and water. 
For the latter, the best mode is to add to very hot water an equal 
quantity of raw whisky. Such appliances should be often renewed, 
or they grow cold. Some persons have a tin vessel constructed to 
hold hot water, and shaped so as to fit over the abdomen. This is 
very good, if it can be used without its weight causing too much 
pressure. The feet of the patient should be kept warm ; if he is able 
to sit up, or recline with the legs over the side of the bed, a hot 
mustard foot-bath will be suitable. 

Kneading the abdomen gently with the hand will aid to dispel flatus ; 
but it requires tact not to make it too violent an operation. In every 
case of violent colic, the possibility of hernia must be held in mind ; 
and its presence or absence should be ascertained. 

Infants are especially liable to crapulent colic ; some, during their 
first year, having almost daily or nightly attacks. Yery simple treat- 
ment will often suffice in these ; in children, too, over-medication 
should be even more sedulously avoided than in adults. For infantile 
colic of slight severity, peppermint water, or infusion of fennel seed, 
will frequently be enough, with the application of a warm flannel over 
the stomach. Worse cases may be treated with lac assafcetidae 
[F. 98] ; which children generally take well, if it be sweetened, in 
teaspoonful or, for very young infants, half teaspoonful doses. Ant- 
acids, as bicarbonate of soda, will assist in giving relief [F. 94]. 
Keeping the bowels regular, never allowing a day to pass without an 
evacuation, is most important in young children. For this purpose 
the simple syrup of rhubarb, manna, and fluid extract of senna are 
the best medicines. The latter may give pain, but is less apt to do 
so if one drop of oil of cloves be added to each fluidounce. A very 
small quantity of resina podophylli added to syrup of rhubarb [F. 95] 

1 Codeia and Narceia are, of late, getting into use, to some extent, instead 
of opium and morphia. Their after effects are said to be less unpleasant. 

15* 



174 DISEASES OF ORGANS OF DIGESTION. 

will make it more potent when the bowels are torpid. Glycerin may 
be occasionally substituted, in teaspoonful doses. 

When the food of an infant becomes acescent, lime-water may be 
added to it when it is taken ; e. g., a tablespoonful of lime-water in 
each pint of milk. Over-feeding an infant is a very common cause of 
colic. 

Bilious colic may be attended with so inflammatory a condition as, 
in a person of full vigor, to demand early and moderate venesection. 
Opening the bowels is a cardinal indication in this as in the flatulent 
form. If the stomach will bear it, castor oil will be the most effectual 
cathartic. The least unpleasant way of taking this is, in thorough 
admixture with spiced syrup of rhubarb ; two tablespoonfuls of the 
latter with one of oil. Magnesia may be retained better than oil upon 
the stomach. Notwithstanding its effervescence, I have known the 
citrate of magnesia solution do very well in colic. The same antacid, 
carminative, and anodyne remedies, mentioned for crapulent colic, 
will be suitable in bilious, and may require more persevering adminis- 
tration. So, also, enemata, mustard plasters, pediluvia, and warm 
applications to the abdomen are of great service. Besides these, 
however, a special indication exists for promoting the hepatic secre- 
tion, so that by greater fluidity and dilution it may be made less irri- 
tating and obstructive. The ordinary treatment, then, is, besides such 
palliatives as have been named, to give calomel, with opium : e. g., % 
to 1 grain of calomel with about as much opium, every two, three, 
or four hours [P. 86]. Leeches, cups, or later, a blister, over the 
liver, may be right, if hepatic or cystic inflammation threaten. 

When there is strong reason to apprehend that the passage of a 
gallstone is the cause of the severe pain, the warm bath, if practicable, 
will be useful by promoting relaxation ; and full doses of opium may 
be called for by the patient's agony. Some prefer to inhale ether, or 
nitrous oxide. 

Gouty, or other cramp of the stomach, is generally in need of 
very prompt treatment ; essentially stimulant and anti-spasmodic or 
anodyne. In moderate cases, Warner's cordial (tinct. rhei et sennse) 
has the advantage of being laxative as well as stimulating ; from a 
teaspoonful to a tablespoonful may be given at once, in hot water. 
In worse attacks, brandy, ether, laudanum, and Hoffmann's anodyne 
are more reliable [F. 97] ; with a sinapism over the epigastrium, and 
a hot mustard foot-bath. Subsequent treatment, prophylactic, of 
future attacks, as with colchicum or other medication, must be pointed 
out by the nature of each case. 

Lead colic, when rapidly produced, may be treated antidotively, 
with sulphate of magnesia. If slowly brought on, we can do much 
less in that way ; although it has been asserted that the iodide of 
potassium has an eliminative power over lead combined with the 
tissues of the body. Alum is confided in by some, for the same end, 
notwithstanding its astringency. Castor oil as a laxative ; the warm 
bath to relax spasm, and opium to relieve spasm and pain, are the 
most important usual remedies in this affection. The costiveness 
being mainly spasmodic, it is not unfrequently found that, contrary to 
its common effect, opium promotes, in lead colic, the movement of the 
bowels. Iodide of potassium is believed to exert a decided power in 



OBSTRUCTION OF THE BOWELS. 175 

removing from the system lead which has been slowly deposited in 
various organs. 

Prevention of Crapulent and Bilious Colic— This becomes the 
duty, if not the interest of the physician ; when his patient has been 
relieved, to aid him in escaping returns of the disorder. To prevent 
the flatulent form, care in diet and regimen will ordinarily suffice. 
For the more seriqus attacks of bilious colic, to which certain persons 
are subject, prevention is attainable by the same means, along with 
especial attention to the abdominal movements and secretions ; i. e., 
the state of the liver and bowels. I am sure that I have enabled 
several persons, who for years had been liable to frequent attacks, to 
escape them altogether, by a very simple prescription, used upon the 
first threatening of any of the symptoms. Blue mass and rhubarb were 
here the sanative agents. A gentleman who has suffered terribly 
with bilious colic told me that twenty grain doses of extract of taraxa- 
cum, taken once or twice, have repeatedly averted it with him. 
Flowers of sulphur, or lac sulphuris, given in teaspoonful doses or 
less, every day or two for several weeks, have answered the same pur- 
pose in another instance. But nothing has so signally satisfied me, 
as a prophylactic against periodical colic, and also, by a similar 
rationale, against sick headache, as the preparation above alluded to ; 
which is as follows : — 

R. — Mass. ex. hydrarg., gr. v. 

Pulv. rad. rhei et 

Ext. gentian, aa ^ss. 

01. caryophyll. gtt. iv. — M. 
Div. iu pil. No. 20. 
S. — One or two occasionally, as directed ; to be continued, if required, 
thrice daily for several days. 

OBSTRUCTION OF THE BOWELS. 

Few maladies present so striking a contrast as this, between the 
facility of pathological explanation after death and the obscurity of 
diagnosis and uncertainty of treatment during life. 

Pathological Varieties. — Dr. Haven has well classified these as 
follows: I. Intermural: a, cancerous stricture; b, non-cancerous 
stricture, viz., 1, contraction of cicatrices from ulceration, 2, con- 
traction of wall of the intestine from inflammation ; o, intussusception ; 
d, the latter with polypi. II. Extramural: a, bands of adhesions 
from lymph; b, twists or displacements; c, diverticula; d, tumors or 
abscesses ; e, mesocolic or mesenteric hernia ; /, diaphragmatic ; g, 
omental, and h, obturator hernia. III. Intramural: impacted feces, 
calculi, coagula, curdled milk. etc. 

Symptoms of Intestinal Obstruction.— These are, persistent con- 
stipation ; constant vomiting, partly or altogether stercoraceous ; 
coldness of the skin, prostration, distressed countenance (fades Hip- 
pocratica), collapse. Local evidences, rather more distinctive, are, 
hardness or swelling in one part of the bowels ; arrest of enemata at 
a certain point, and of borborygmi (gaseous movements) in the same 
way. If the obstruction be high up, suppression of the urine occurs, 
with early vomiting. If it be low down, great meteoric distension and 



116 DISEASES OF ORGANS OF DIGESTION. 






stercoraceous vomiting. When blood is passed from the bowels, with 
such symptoms, intussusception may be inferred. 

But, at last, a probable diagnosis is all that the nature of the case 
will admit. The differential discernment of special forms of obstruc- 
tion during life is impossible. 

Treatment. — The simple, primary indication in persistent constipa- 
tion, with unrecognized cause, is catharsis. Castor oil, sulphate of 
magnesia, croton oil, are, justifiably, given, aided or seconded by ene- 
mata of the same or similar purgatives. When the diagnosis of intes- 
tinal obstruction has been well made out, no more cathartic medicines 
are to be given ; the reliance then being upon nature and opium. The 
latter drug may be prescribed in grain or half-grain doses every few 
hours, to sustain a tranquillizing effect favorable to relaxation of the 
intestinal coats. Besides, we may try large enemata of warm water ; 
or inserting a bougie, or stomach-tube, to catheterize the bowel, as far 
as the ileo-csecal valve: or, the Hippocratic remedy of large air in- 
jection, to distend and dislodge the intestine. This has succeeded in 
several cases of intussusception. Scybala, or impacted feces, or co- 
agula, &c, may be removed by a spoon or scoop from the rectum. 
Prolonged use of the warm bath may be tried to relax the system ; and, 
as in strangulated hernia, the tobacco injection may become allowable 
as an extreme resort. 

COMMON REMEDIES IN COLIC. 

The following are put together simply as memoranda : — 

Peppermint, Fennel, Cajeput ; Assafcetida ; 

Lavender, Ginger ; Hot water ; 

Aromatic spirit of ammonia; Brandy; 

Bicarbonate of soda; Calomel; 

Magnesia; Castor oil; Enemata of oil, or 

Warner's cordial; Olive oil; Spirits of turpentine, or 

Camphor, Ether, Chloroform ; Laudanum ; 

Opium, in pill ; Paregoric or Sinapisms and 

Laudanum ; Pediluvia ; Kneading ; 

Hot flannel or plate; Warm bath. 

Remember, always, the possibility of strangulated hernia as a cause 
of the symptoms of colic. 

CHOLERA MORBUS. 






This very unscientific name has become inseparably attached to 
what in technical phrase may be most briefly called idiopathic emeto- 
catharsis ; i. e. vomiting and purging, neither brought on by irritant 
poisons, nor by an epidemic influence. The account I shall give ap- 
plies best to such an affection as we commonly meet with it in this 
country, especially in the summer. English medical writers describe 
it sometimes as English cholera; others, sporadic cholera. 

Symptoms. — Nausea, and vomiting of greenish or yellowish fluid, 
with rejection of all food and drink ; often, but not always, pain in the 
stomach and bowels ; diarrhoea, with brownish or yellowish stools ; 
debility, and coldness ; little or no fever. Beginning with such symp- 



DIARRHOEA. 1YT 

toms, if the attack, not relieved, becomes aggravated, cramps in the 
limbs supervene; the vomiting and purging become more watery; 
prostration and coldness deepen into collapse, — which may be fatal! 

Causation. — Warm weather seems to predispose to it, by relaxing 
the mucous membranes and exciting the liver. Direct causes often 
are, indigestible articles of food, as unripe fruit, &c. ; excess of ordi- 
nary food ; sudden change of temperature, checking perspiration. 

Diagnosis. — From epidemic cholera, it is important to distinguish 
cholera morbus ; as the prognosis is not the same, nor will the same 
treatment answer for both. The difference is seen in the bilious 
vomiting and purging of cholera morbus, and rice-tvater discharges 
of cholera; the greater nausea in the former; much more tendency to 
collapse, with blueness, dyspnoea, and suppression of urine, in cholera. 
The presence or absence at the time of an epidemic of the latter may 
complete the diagnosis by confirming or correcting the evidence of 
the above signs. It is only in an extreme case of cholera morbus that 
any real difficulty should exist. During, and before and after, the 
prevalence of epidemic cholera, an especial tendency to cholera mor- 
bus, as well as diarrhoea, often exists. This, called cholerine, may 
present more near resemblance to malignant cholera than our ordinary 
summer attacks. 

Treatment. — A large sinapism should be at once placed over the 
epigastrium. All theory or rationale apart, the following mixture is 
admirably useful in ordinary summer cholera morbus: — 
R. — Sp. ammon. aromat. f£j. 
Magnes. optim. gj. 
Aquae menthse piperitae f§iv. — M. 
To be shaken when taken. 
S. — A teaspoonful every twenty minutes. 

Few cases will fail to be relieved in an hour or two if this be given 
early. 

When the diarrhoea is copious, or the case is seen rather late, pare- 
goric may be added to the above, — fgij or f^ss in the same mixture. 
When purging is very urgent and exhaustive, instead of magnesia a 
like amount of bicarbonate of soda may be used. Infusion of cloves, 
cinnamon, or ginger may assist to quiet the stomach in an obstinate 
case. After the sinapism, a spice poultice, of ginger, cloves, and cin- 
namon, each a full teaspoonful, with a tablespoonful of flour, moistened 
with brandy, should be applied. Ice may be given if thirst be great. 

Extreme prostration may require the use of brandy internally. To 
check the diarrhoea and vomiting when threatening collapse, a lauda- 
num and starch enema (40 to 60 drops of laudanum in ^ ounce of 
starch) may be given ; and a blister may be applied over the stomach, 
the part to be dressed, when vesicated, with 2 grains of acetate of 
morphia mixed with 10 of powdered gum-arabic. 

DIARRHOEA. 

Though rather a symptom than a disease, excessive discharge from 
the bowels often requires express treatment for its relief. 

Varieties. — These are, principally, 1. Irritative diarrhoea, as from 
dentition ; 2. Inflammatory, as in enteritis ; 3. Symptomatic, as in 



178 DISEASES OF ORGANS OF DIGESTION. 

typhoid fever; 4. Critical, as at the close of remittent fever; Elimina- 
tive. as in septic or other poisoning; Colliquative, as in phthisis. 

The character of the discharges varies very much. They may be, 
1. Fecal, although liquid ; 2. Bilious ; 3. Mucous ; 4. Serous ; 5. Adipose 
(very rare). 

Except in the beginning of attacks, discharges are rarely fecal in 
character when much beyond the normal amount. The gutter-water 
discharges of typhoid fever often have nearly the fecal appearance 
except in consistence. Mucous discharges occur in enteritis, and in 
many cases of summer diarrhoea. Bilious passages occur in cholera 
morbus. Serous, or ''rice-water," in malignant cholera. 

Treatment. — An important point is, that in many cases diarrhoea 
ought not to be abruptly checked ; in some it should not be interfered 
with at all. The latter is true of the looseness of the bowels in typhoid 
fever, if the passages are not more than three daily, and are but 
moderate in amount. When excessive in that disease, they require 
checking, not arresting. 

Ordinary summer diarrhoea, the most nearly "idiopathic" of all 
forms, demands correctives, generally, before or with astringents. 
Blue mass or hydrargyrum cum creta ; magnesia, with charcoal or with 
aromatic syrup of rhubarb [P. 101] ; bicarbonate of soda, with ginger 
or cinnamon, etc., will often relieve the condition of the alimentary 
canal in which diarrhoea originates, and thus end it without any 
astringents. 

When the latter are indicated, by continuance or increase of the 
discharges, chalk mixture has long held a routine place as an early 
prescription. Instead of it some prefer testa pra3parata, or oculi 
cancrorum. In infants, lime-water, with cinnamon or camphor water, 
will do for mild cases. Kino, catechu, krameria, and hgematoxylum 
are familiar as pure astringents. The addition of opium, or camphor, 
or both (as in paregoric) in small doses to such preparations is gen- 
erallv proper, to increase the binding effect, even in the absence of 
pain" [F. 101, 102,103, 104]. 

More obstinate cases should be treated with tannin (gr. iij in pill, 
with ^ or J grain of opium, pro re nata), or pills of acetate of lead 
and opium (gr. j of the acetate, with gr. £ of opium) every three or 
four hours ; or a mixture containing acetate of lead with acetate of 
morphia ; aided when necessary by enemata of laudanum and starch 
(30 to 60 drops of laudanum to i ounce of starch, cool or cold). As 
an article of diet in feeble cases, arrowroot with brandy will be espe- 
cially suitable. 

In chronic diarrhoea, besides the remedies last mentioned, some- 
times enemata of acetate of lead solution, or of some other mineral 
astringent, will do good. Mention of these will be again made in con- 
nection with chronic dysentery. 

The food in cases of diarrhoea always requires regulation. Vegeta- 
bles and fruits, as a rule, ought to be forbidden ; the popular prejudice 
which makes the blackberry an exception I believe to be a mistake. 
It has had its origin in the known astringency of the root. Boiled 
rice, and other farinacea, will nearly always be suitable. In severe 
cases, all solid articles of food should be withheld. 

Scorbutic diarrhoea, however, from the nature of its cause, demands 



CHOLERA INFANTUM. 179 

a quite different regime. Officers in the army who were affected with 
diarrhoea on the Chickahominy in IfcClellan'e campaign, have told me 
that, when astringents had'no effect in checking the complaint, toma- 
toes, peaches, and lemonade cured it at once. 

CHOLEBA INFANTUM. 

Popularly known as " summer complaint ." this affection is very de- 
structive to young children in the large cities of this country, in hot 
weather. The peculiar influence of high heat in an atmosphere con- 
taminated by ''town" causes, generates it. In New York and Phila- 
delphia, its prevalence and mortality coincide with the rise of the 
thermometer above 90 c . The deaths for the hottest week in July, 
1866, in New York were over 1200, and in Philadelphia over 700 ; 
more than in either city during the prevalence of cholera later in the 
same season, and more than twice the usual mortality. 

Symptoms. — These are, diarrhoea, vomiting, rejection of food, 
languor, debility, apathy; sometimes stupor. At first the head may 
be hot, the abdomen swollen ; as the case progresses, coldness and 
emaciation supervene. In some, with predominance of cerebral symp- 
toms, death may be threatened after a very few days of sickness. In 
others, copious diarrhoea and constant vomiting endanger the same 
result. In many, however, without violent symptoms, the child is 
gradually reduced by diarrhoea and inanition. The period of dentition 
is particularly liable to this disorder; it seldom occurs after four years 
of age. 

Pathology. — Although decided alteration of the follicles of the 
intestines, with some change in the general appearance of the mucous 
membrane, has been shown to be generally present after death from 
cholera infantum, the disease is most probably rather a systemic than 
a local one. Its seat must be in the whole nutritive apparatus, in- 
cluding the ganglionic nerve-centres. Sanguification is evidently 
impaired, and an imperfect blood deranges the action of the brain and 
spinal cord; hence the stupor, or extreme apathy, and, in some bad 
cases, convulsions. 

Treatment. — Correctives are, here, especially important in the 
beginning. I am. from considerable experience, a full believer in the 
great value of moderate doses of calomel in the early stages of summer 
complaint. 1 would always give it, with an antacid [F. 107]. When 
stomach or head symptoms predominate, with but little diarrhoea, 
calomel with magnesia will do the best. "When there is more loose- 
ness, bicarbonate of soda should be used, with the calomel, instead. 
Spiced syrup of rhubarb may be added to either. Hydrargyrum cum 
creta is 'the preferred mercurial with many practitioners. I have 
found it to answer very well, after or even perhaps instead of calo- 
mel. 

A spice poultice or plaster should be kept over the abdomen so long 
as vomiting continues ; being renewed or wet freshly with brandy often 
enough to maintain its strength. Ice (pounded in a rag for young 
infants) may be given more often than water to quench thirst. The 
food may be lime-water and milk, arrowroot, farina, chicken-water, 



180 DISEASES OF ORGANS OF DIGESTION. 

beef-tea. After the first stage, many children will require small quan- 
tities of brandy (preferably with their food) for support. 

In the early stage, if the head be hot and stupor be threatened, a 
few leeches behind the ears, and the application of cold water, upon 
a light cambric handkerchief, to the head, may be proper. Such a 
stage, however, does not often last long. 

Later, the two difficulties are, to check the diarrhoea, and to over- 
come the rejection of food by the stomach. For the bowels, astring- 
ents are then called for ; especially logwood, blackberry root, geranium, 
krameria ; aided in serious cases by paregoric in small quantities by 
the mouth, or even the injection into the bowels of one, two, or three 
drops of laudanum with starch. Sometimes acetate of lead injections 
(from one to three grains, with starch) may be farther needed, for the 
same intent. 

Protracted summer complaint affords scope for perseverance and 
contrivance in finding food available for the child. Well-made beef- 
tea agrees with most children. Raw beef scraped or rasped fine, has 
been found to answer the purpose best with some. 

But all medical treatment may fail in some cases of cholera infan- 
tum, which will speedily recover on being removed from the city to 
the country. The immediate effect of a salubrious air is ©ften sur- 
prising and delightful. 

Prophylaxis. — This is very clear and simple. A child under five 
years of age ought never to be kept in the close-built parts of a large 
city, in our climate at all events, through June, July and August, if it 
can be helped. Next to a residence for the summer in a high and 
open country, will be the benefit of frequent excursions or visits ; 
riding or sailing ; or even, if nothing else be possible, being carried 
daily into the squares or parks of the city. 

DYSENTERY. 

Definition. — An inflammation of the large intestine, involving the 
muscular as well as the mucous coat. 

Varieties. — Acute and chronic ; sthenic and asthenic ; endemic or 
epidemic ; bilious ; ulcerative ; strumous or tuberculous. 

Symptoms. — Fain in the lower half of the abdomen, with soreness 
or tenderness on pressure or motion ; frequent disposition to go to 
stool, with small and bloody or blood-marked muco-fecal or mucous 
passages, sometimes containing shreds of lymph or false membrane ; 
tendency to strain (tenesmus) with griping (tormina) ; fever in most 
acute cases. 

Severe and protracted cases may be considered as going through, 
1st, the inflammatory, and 2d, the ulcerative stages. 

Simple acute dysentery is commonly sthenic, or open, active, and 
inflammatory, without early or great tendency to prostration. En- 
demic or epidemic dysentery (the first name is the more correct) is 
generally asthenic, in this form fever may be absent, or brief, or of 
a typhoid character. Vomiting is not rare in this, as it is in the ordi- 
nary acute form. Coldness and debility come early. 

Sometimes, in malarial districts, dysentery, like all other maladies, 
may be intermittent ; with daily or tertian exacerbations and intervals. 



DYSENTERY. 181 

Morbid Anatomy- — Redness, tumescence, thickening, softening, 
ulceration, suppuration, and occasionally pseudomembranous deposits, 
are, after death from dysentery, found, in various degrees, in the 
rectum, colon, and caecum ; chiefly in the lower bowel. The hemor- 
rhage which makes the typical bloody stools, is due to the congested 
and inflamed mucous membrane being constricted, in the tenesmus, by 
spasmodic and irregular contractions of the muscular coat. 

Chronic dysentery presents nearly always ulceration of the rectum 
or colon, or both. The discharges in this may become almost entirely 
muco-purulent. 

Causation. — Predisposition to dysentery is common in the latter 
part of summer ; in this city and neighborhood, from the middle of 
August to the end of September especially. Relaxation from heat, 
with sudden exposure to cold and wet, may produce an attack. So, 
often, will indigestible food ; as unripe fruit. Bad drinking water is 
another cause. 

At any season and locality such agencies may produce simple acute 
dysentery. But in certain regions it becomes at times endemic. This 
is particularly noticed in many localities having considerable elevation, 
not subject to malarial fevers, but within a short distance of ague 
districts ; dysentery upon the hills, while intermittent and remittent 
occur in the adjoining or subjacent valleys and meadow lands. 

Prognosis. — Either form of dysentery may be fatal ; but the en- 
demic and asthenic type is much the more dangerous. The other, 
with good early treatment, is generally quite manageable. When 
allowed to become chronic and ulcerative, the doubtfulness of re- 
covery is much greater. Bilious dysentery, that is, the form in which 
disorder of the liver is a prominent feature, the discharges presenting 
an excess of more or less altered, irritating bile, is more intractable 
than ordinary simple dysentery. 

Treatment. — Simple acute form. — Now and then we may find a 
robust patient who will require to be bled during the first, active, 
stage of dysentery. Much more often, leeches over the abdomen, 
where the tenderness is greatest, will be suitable. After these, warm 
poultices, of flaxseed meal, mush, &c, may be put on. Later, in ob- 
stinate cases, a large blister, in the same region. 

At the very start, the old practice of beginning with a dose of castor 
oil, with ten or fifteen drops of laudanum, will do very well. If left 
for a day or two, it had, as a rule, better be omitted. 

Then the first prescription, in a mild or moderate case, may be of 
blue mass with ipecacuanha. After one or two days (sooner in an 
urgent case), camphor may be added, in pill. Next, we may substitute, 
for the blue pill, opium; afterwards, omit the ipecac, continuing the 
opium and camphor, pro re nata. If the disorder be still not checked, 
we must resort to acetate of lead, with opium, or in solution with 
acetate of morphia [F. Ill, 112, 113, 114]. 

Perfect rest is indispensable to prompt recovery from dysentery; 
there is no disease in which this can be more important. 

The diet must be bland ; as rice-water, arrowroot, or other farinacea; 
chicken-water, or beef-tea in the feeblest cases. When thirst is intense, 
iced rice-water or benne-leaf tea, or infusion of slippery-elm bark, may 
16 



182 DISEASES OP ORGANS OF DIGESTION. 






be used as a drink ; or, during the active stage, ice in substance may 
be taken slowly. 

Enemata are very important in dysentery. First, of flaxseed-tea, 
as a demulcent (two to four fluidounces at once) ; the same with 
laudanum; or laudanum with starch [F. 115]. In chronic cases, or 
obstinate acute ones, acetate of lead may be given by enema, with 
laudanum, in mucilage. So may sulphate of zinc, and nitrate of 
silver. I have seen some remarkable cures of chronic dysentery by 
the use of an enema containing ten grains of sulphate of zinc, forty 
drops of laudanum, and four ounces of flaxseed tea. Such an injection 
may be painful at the time, and would be too irritating except in an 
ulcerative case of considerable standing ; for which it should be re- 
served. Solution of tannic acid, in water or in glycerin, will be worthy 
of trial for a similar purpose. 

Asthenic, endemic form. — In this there will be need of the earlier 
use of opium ; and, often, of quinine, and stimulants. No leeching, 
or little, is likely to be well borne ; and ipecac, may be prohibited by 
vomiting. When it can be taken, in small doses (not more than £ a 
grain), I believe it to be a valuable remedy. When malarial influence 
is obvious, and most of all in the intermittent form, quinia or cinchonia 
will be the remedy, to which others are adjuvants [F. 117]. Hope's 
mixture will be more likely to do good in this, the adynamic, than in 
the simple acute form. (R. — Acid, nitric. f£ j ; tinct. opii, gtt. xl; 
aquae camphorse, f^viij ; dose a tablespoonful.) 

Bilious Dysentery. — As a distinctive variety, this is not uncom- 
mon ; and, if it last over ten days, it may be very hard to cure. 
Ordinary anti-dysenteric medication will not be inappropriate to it — 
but may disappoint much more than it is apt to in simple acute cases. 
Without having a very satisfactory recollection of the results of treat- 
ment of such cases in my own experience, I should trust most in the 
withholding of mercurials in the first stage, the gradual introduction 
of one of them in the second week, the application of a blister at the 
same period over the liver, and, besides opium, acetate of lead, &c, 
as called for for astringent effect, the administration of nitro-muriatic 
acid. Of course the chemical incompatibility of this with lead must 
be remembered ; but this will not interfere with saturnine injections 
while using the acid by the mouth. 

HEMORRHOIDS. 

Definition. — Piles ; tumors, at the verge of the anus, or within the 
rectum. 

Varieties. — External and internal ; varicose and fibrous ; dry and 
bleeding. 

Symptoms. — At first, weight and fulness in the rectum ; soreness 
about the anus ; pain, increased upon having a stool. The pain may 
extend up the loins, and down the limbs, even to the feet. As in- 
flammation increases, throbbing and aching may become almost con- 
stant. Swelling, and then the formation of one or more distinct 
tumors, occurs. If without the anus, there may be every variety of 
painfulness, aggravated at certain times. If internal, the prolapsus 
of the tumor during defecation, and its constriction or strangulation 



HEMORRHOIDS. 183 

by the sphincter ani, cause great suffering" : often the tumor requires 
to be put back by the hands. Occasionally it cannot be returned, but 
undergoes mortification and sloughing away. Bleeding occurs from 
internal haemorrhoids. The amount may vary from a teaspoonful to 
a pint or more in a day. Cases are recorded by good authorities in 
which several pounds of blood have been lost in a single night. 
Commonly it is much less ; but may be enough to blanch and reduce 
the patient to the extreme of anaemia and debility. 

Anatomy. — Inspection shows external piles to be globate, broad- 
based tumors, at the verge of the anus, covered by thin integument; 
livid in color when fresh, losing that hue when old : tense and elastic 
to the touch, and very tender, at least during inflammation. 

The old idea that every haemorrhoid is a dilated vein, has been cor- 
rected by observation. Piles consist of distended skin and connective 
tissue, with contained extravasation of blood, and deposit and organi- 
zation of lymph, from local congestion. 

Internal haemorrhoids are described as chiefly of three varieties : 
1st. Solid, round or pear-shaped, attached by a peduncle, smooth, and 
dull in color; composed of mucous membrane, connective tissue, and 
thickened veins. These bleed very little if any. 2d. Broad-based, 
bright-red, spongy tumors, villous on the surface, and bleeding readily, 
arterial blood ; consisting of loose folds of mucous membrane, with 
hypertrophied connective tissue, and enlarged capillary and small 
arterial and venous vessels. 3d. Florid, very vascular excrescences 
upon the mucous membrane, not of large size, but bleeding sometimes 
copiously. 

Complications and Sequelae. — These are, especially, ulceration, 
abscess, fistula, fissure of the anus, prolapsus ani, and sympathetic 
irritation of the urethra, bladder, prostate, or testicles in the male, or 
of the uterus and vagina in the female. Sloughing of a strangulated 
hemorrhoidal tumor is considered by some to endanger life ; but my 
own observation of its occurrence would lead me to depreciate this 
danger. Certainly very fine natural cures thus occur. 

Moderate bleeding from inflamed haemorrhoids gives temporary re- 
lief. When habitual and not excessive, its sudden arrest may possibly 
promote some internal visceral congestion. — as apoplexy. 

Diagnosis. — Haemorrhoids may be mistaken for venereal excres- 
cences, or polypi of the rectum, or for prolapsus ani. The first are 
harder, more abrupt in their elevation and margins, and of a quite 
different history ; in addition to which other marks of the syphilitic 
constitution exist. Polypi are of slower growth, and unaccompanied 
by inflammation, or, as a rule, by hemorrhage ; and their surface is 
smoother than that of piles. Prolapsus ought to be easily made out, 
by examination disclosing the structure of the everted mucous mem- 
brane. 

The source of bleeding from the rectum may sometimes be in doubt, 
as to whether it be hemorrhoidal or not. True hemorrhage from the 
bowels, other than from piles, is the result commonly of serious and 
obvious disease ; as typhoid fever, yellow fever, kc. Such flow of 
blood is itself painless, and the blood is dark, clotted, and variously 
mixed with fecal matter when passed ; and the symptoms of piles are 
absent. 



184 DISEASES OF ORGANS OP DIGESTION. 

Causation. — Hereditary predisposition sometimes exists. Haemor- 
rhoids are uncommon in either sex before puberty; in females they 
are most frequent at the time of the cessation of menstruation. Warm 
and damp climates promote them ; as in the East and West Indies, &c. 
The plethoric constitution is the most liable to them ; especially with 
sedentary habits. Pregnancy is attended by them not unfrequently. 
Other causes are, long standing, or sitting upon hard seats, excessive 
venery or self-abuse, over-stimulating diet, misuse of purgatives, espe- 
cially of aloes, ascarides, diarrhoea, dysentery, stone in the bladder. 
Constipation of the bowels always predisposes to haemorrhoids. 

Treatment. — This must be both general and local; the former 
depending upon the constitutional condition, and the cause of the 
affection. The bowels must be regulated; neither over-purged nor 
allowed to be costive; a soluble state is the most desirable. The 
bleeding of piles must be but cautiously interfered with, if it has been 
habitual, or if there is a tendency to apoplexy, phthisis, gout, or in- 
sanity. 

The diet must be made to consist of digestible and unirritating food. 
Long standing and sitting, or rough riding, must be avoided; although 
active exercise in the open air may be very advantageous. 

External piles may often be averted in the forming stage, by atten- 
tion to the bowels, along with the frequent application of the simplest 
unguents to the irritated and swollen part. Lard, tallow, cold cream, 
or simple cerate, or spermaceti ointment, will answer very well ; but 
the grease should be applied several times daily, and especially after a 
stool, — so as to keep the part constantly soothed by it [F. 118, 119, 
120, 121]. 

The laxatives most approved for haemorrhoidal cases are rhubarb, 
sulphur, and senna. The confection of senna is a very good prepara- 
tion for such use. Magnesia is irritant to piles ; and so are, though 
in less degree, the saline cathartics. Enemata are objectionable merely 
because of the mechanical pressure of the instrument. In internal 
haemorrhoids they are often decidedly serviceable. When piles are 
inflamed, washing with cold water, or a cool sitz-bath, may relieve. 
Some patients prefer warm water under the same circumstances. 

When bleeding is so considerable as to need to be checked, cold 
water injections, or solution of alum, or tincture of iron, may be em- 
ployed. A piece of alum made into a smooth suppository will some- 
times do. In really threatening hemorrhage, the patient must lie still 
in bed. 

On the other hand, inflamed non-bleeding piles may require local 
depletion, by leeches, or, as many prefer, cupping over the sacrum. 

Prolapsed internal haemorrhoids often have to be replaced by the 
hand. Oiling will of course facilitate such reduction. 

Astringent ointments, as of galls, tannin, carbonate of lead, or 
creasote, with regimen and laxatives, may cure piles even of consider- 
able standing. But old and obstinate cases demand removal by opera- 
tion. 

External haemorrhoids should be excised, with curved scissors or a 
probe-pointed straight bistoury ; taking off no more integument than 
what covers the tumors. Good authority, however, pronounces touch- 
ing carefully with nitric acid to be safe and successful. 



FISSURE OP THE ANUS. 185 

Internal haemorrhoids ought, when operated upon, to be removed 
always by ligature. Excision is dangerous, and has several times been 
fatal, by hemorrhage. Some prefer cauterization with nitric acid. In 
ligating haemorrhoids, it is best to apply a double ligature around the 
base of each tumor. Silk or hemp will answer; Bushe's needle- 
receiver is a good instrument for the application. 

FISSURE OF THE ANUS. 

This is a very painful and not uncommon affection, especially in 
middle life ; perhaps most frequent in females. Neglected constipa- 
tion and haemorrhoids, with relaxation of constitution and sedentary 
habits, are its principal causes. 

Its symptoms are, — at first, soreness or smarting at one point of 
the anus at stool. This becomes afterwards very severe; with intense 
pain, burning, aching and throbbing, and violent spasmodic constric- 
tion of the sphincter ani, lasting sometimes for hours. 

Examination displays a lesion mostly of the mucous membrane only; 
though occasionally reaching even to the muscular fibres of the sphinc- 
ter. In the beginning only a crack, it becomes at last an extended 
ulcer; and may exist on each side of the anus. 

The stools are streaked with pus or blood, and often reduced in 
size by the spasm of the rectum ; suggesting stricture of the rectum : 
for which this complaint has now and then been mistaken. The 
suffering of the patient in bad cases is extreme ; pain being produced, 
not only by defecation, but also by coughing, sneezing, stimulating 
food, or even by the sitting posture. 

Treatment. — Most cases, even of long standing, may be cured with- 
out an operation. The fissure may be managed as an irritable ulcer ; 
by the constant application of soothing unguents, — as spermaceti or 
oxide of zinc ointment, lead cerate, unguentum belladonnas, or lime- 
water with oiled silk dressing. The latter will be convenient only in 
the recumbent posture. Experience in analogous cases would lead 
me to have especial confidence in collodion, to which one-fiftieth of 
glycerin has been added to lessen its constricting effect. This may 
be painted upon the part with a camel's hair pencil, as in fissure of 
the nipple ; it makes an excellent artificial cuticle. 

Obstinate cases may be treated also with nitrate of silver or sulphate 
of copper, applied every day or two, lightly, to the surface. Where 
suffering is great, suppositories of opium and cocoa butter, or of bella- 
donna, may be introduced after defecation. Washing with soap and 
water, twice daily, will be serviceable. 

Should all such measures fail, Boyer's operation, as modified by 
Copeland and Brodie, should be resorted to. It is, incision through 
the ulcer, with a bistoury, either from within outward, or from without 
inwards. It is only necessary to cut through the mucous membrane, 
not through the sphincter. Mild dressings must follow the incision ; 
which will usually produce rapid recovery. 

Dr. W. H. Vanburen's operation consists in the forced dilatation 
of the sphincter ani, by the two thumbs of the operator ; so as to 
overcome the spasmodic contraction. 

16* 



186 DISEASES OF THE LIVER. 



PROLAPSUS ANI. 

Partial descent of the rectum without the anus is not rare in the 
adult, but is more common in children. Relaxation of the mucous 
membrane, or weakening of the anal muscles, may induce it ; straining 
at stool is its usual immediate cause. Tropical countries afford its 
most numerous examples. 

Treatment. — The protruded bowel must be replaced. Commonly, 
gentle pressure, with lard or oil, and tact, will succeed at once. If 
not, leeches and cooling applications must be applied to reduce con- 
gestion and swelling. Sometimes anaesthesia will be a needful aid ; 
but not often. 

Having effected the replacement, a pad and T bandage will main- 
tain it for the time. The bowels must then be carefully regulated. 
For the rest, preventive care is the main thing. Children affected 
with prolapsus must not be allowed to strain. The chair or other 
seat used by them ought to be high, so as not to flex the thighs much 
upon the body. The more nearly erect the posture, the less force in 
the bearing down. 

Old prolapsus in the adult may not be curable without operation ; 
although the air-dilated gum-elastic pessary will sometimes give relief. 
I refer for the operation to works on Surgery. 1 



AFFECTIONS OF THE LIVER. 

ACUTE CONGESTION. 

This, with deficient secretion of bile, is very common, as the resul 
of exposure to cold and wet in warm seasons or climates, of the chill 
of intermittent, or of excesses in diet. Its symptoms are, a sense of 
weight and slight or moderate pain in the right hypochondriac region 
and under the right shoulder-blade, constipation with lead-colored 
stools, nausea, a furred tongue, bitter taste in the mouth, a yellowish 
skin and conjunctiva, and headache or dizziness. 

Treatment. — Two or three grains of blue mass at bedtime, one, 
two, or three nights (two grains only if repeated). When decided 
constipation exists, one purging dose in the morning of sulphate or 
citrate of magnesia, or of magnesia. Then ten or fifteen grains of 
bicarbonate of soda twice daily, with light diet. 

CHRONIC CONGESTION OF THE LIVER. 

A number of attacks of temporary hepatic congestion, or of hepatitis, 
or prolonged dyspepsia, or intermittent or remittent fever, may induce 
a chronic hyperemia of the liver, with variable disturbance of function. 
Fain in the right side and shoulder, with sallowness of complexion, 
constipation, and lowness of spirits, are the principal symptoms. 

Treatment. — Supposing blue mass to have been temporarily and 
sufficiently used, as the leading cholagogue (so established by ample 

1 See Ashton on the Rectum, p. 157. 



HEPATITIS. 187 

clinical proof, notwithstanding the failure of a portion of the physio- 
logical experimentation upon the subject), nitromuriatic acid may be 
then given, 3 or 4 drops twice or thrice daily, for two or three weeks 
successively. Or it may be used in a bath (f.?vj-viij in each gallon 
of water). Taraxacum, 10 or 20 grains of the extract twice daily, or 
a wineglassful, as often, of the decoction of the root, or the fresh leaves 
in spring or summer, eaten as greens, may follow. Leptandrin (dose, 
gr. j-iij) is said to be mildly cholagogue and safe. Ordinary laxatives, 
as rhubarb, etc., may be used to regulate the bowels. Care of the 
skin, by bathing, proper clothing, and, if chilly, friction with hair 
gloves or a rough towel (salt bathing will be very good) is important. 
Exercise in the open air, not violent, should be had every day. 
Change of air, mineral waters, or sea bathing, may be advised. 

HEPATITIS. 

The most common form of inflammation affecting the liver is what 
some writers call " gastro-hepatic catarrh ;" considered on a previous 
page. There is reason to believe the duodenum, stomach, gall-duct, 
and liver to be all in variable degree involved in such attacks. 

Hepatitis may also be traumatic. Whether so or idiopathic, either 
the parenchymatous tissue, Glisson's capsule, the biliary ducts, or the 
portal vein, or all together, may be the seat of inflammation. 

Some of the symptoms are nearly the same in all cases, and are in 
part the same as in acute congestion of the liver; but the pain in the 
side is greater, with some tenderness on pressure ; there is fever, often 
vomiting, and sometimes diarrhoea. 

In inflammation of the capsule (perihepatitis) the tenderness on 
pressure, movement, or deep inspiration, is considerable ; the fever, 
slight or absent ; and there is no jaundice. This may sometimes be 
confounded with diaphragmatic pleurisy ; but there is, in the latter 
complaint, more severe pain, with cough, dyspnoea, and hiccough. 

Inflammation of the portal vein may proceed to suppuration. Then 
the symptoms are scarcely distinguishable from those of hepatitis with 
abscess, to which attention will be given presently. 

When inflammation is chiefly confined to the gall-bladder and ducts, 
the points of diagnosis are, the comparative absence of fever, and the 
considerable degree of jaundice. 

Abscess of the Liver. — Although much most common in tropical 
climates, this may be met with anywhere. Besides the usual symp- 
toms of hepatitis, when pus is forming, we find rigors, recurring 
almost regularly as in intermittent, a very rapid pulse, prostration, 
copious perspirations, and loss of flesh. In a considerable number of 
cases, however (13 per cent, according to Louis), the disorder is latent ; 
being made known only by the consequences of suppuration. 

The greatest danger attends the escape of pus from the abscess. 
This occurs spontaneously either through the diaphragm by the lungs, 
into the stomach, or intestinal canal, into the peritoneal cavity, or, in 
a minority of cases, through the skin. Any of these may be followed 
by recovery, except the escape into the cavity of the peritoneum. In 
this instance, death is almost certain. 

The causes of abscess of the liver, besides the predisposition belong- 



188 DISEASES OF THE LIVER. 

ing to hot climates, are 1. Blows or wounds ; 2. Inflammation of the 
portal vein, with transfer and deposit of pus; or thrombosis from 
some other vein, as the hemorrhoidal ; 8. Dysenteric ulceration ; 4. 
Inflammation and suppuration of the gall-bladder or gall-ducts. 

Treatment of Acute Hepatitis.— A highly febrile case in a vigor- 
ous subject may be treated by early venesection. Otherwise, leeches 
to the right hypochondrium will be suitable. All mercurials should 
be avoided. Saline cathartics are proper, with rest in bed, low diet 
and cooling drinks. A blister may follow leeches or cupping. 

The most serious question occurs when suppuration is known or 
believed to have taken place. Can we prevent or lessen the dangers 
of the discharge of the abscess ? Nature in many cases makes this 
secure, by adhesion of the liver to the stomach or bowel, so as to 
allow of the direct flow of the pus into the canal. In other instances, 
deep-seated fluctuation may be felt below the edge of the ribs. Possi- 
bly this might be, a dilated gall-bladder, or hydatids of the liver. 
But, if sure that it is an abscess, ought we to open it ? The most 
prudent answer is, not unless we are confident that only the skin 
intervenes between the pus and the exterior. A very judicious 
medium between this and bolder practice has been proposed by Dr. 
Graves : to make an incision about four inches long right over the 
centre of the tumor, but reaching through the muscle to within a. few 
lines of the peritoneum. This, even when the matter is deeply seated, 
is shown by experience to favor and hasten essentially its escape, 
without the dangers of a peritoneal incision. Even acupuncture, or 
the use of the exploratory needle-trocar, will be both less safe and 
less beneficial than this plan. 

After the discharge of the abscess, convalescence may be expected ; 
it is sometimes rapid, but may require a month or two. 

JAUNDICE. 

Icterus or jaundice is a morbid yellowness of the skin, eye, and 
other parts. It has no uniform pathology, causation, or concurrent 
symptoms ; but is itself so marked an occurrence as to deserve special 
study. Sometimes it is even epidemic ; as in the U. S. Army in 
malarial districts during the late war; to the extent of over 10,000 
cases in a single year. 

Varieties. — As to degree, — yellow, green, and black jaundice. As 
to causation, jaundice from suppression, and from re-absorption of 
bile ; and icterus neonatorum, jaundice of young infants, of still differ- 
ent origin. 

Symptoms. — In ordinary acute cases of jaundice, either suddenly 
or after some days of malaise, the whites of the eyes first become 
tinged with yellow ; next, the roots of the nails, the face, neck, trunk, 
and limbs. The urine is of a porter color, stains linen yellow, and 
becomes green on the addition of nitric acid. At the same time the 
stools are slate or lead-colored, or almost white. The mouth has a 
bitter taste, and the patient suffers with lowness of spirits and indis- 
position for exertion. 

Pathology and Causation. — Many affections of the liver may in- 
duce jaundice ; although in some of the most serious of them it may 



JAUNDICE. 189 

be absent. Most distinctly it is traceable in different cases to the non- 
removal of the biliary coloring matter, as well as of cholesterin, from 
the blood by the liver; other organs, especially the skin, then receiv- 
ing it; or, to obstruction preventing its transit, after secretion, through 
the intestinal canal, in which case it is reabsorbed into the blood and 
then thrown out elsewhere. 

The remote causes of jaundice of greatest frequency are, malaria, 
exposure to cold and damp in hot weather, pregnancy, and violent 
mental emotion. 

' Diagnosis. — In either form of jaundice we have the yellow con- 
junctiva and skin ; or serum, if a blister be applied, or blood drawn ; 
in both the stools are without color, and the urine yellow or yellowish- 
brown. But, as Harley first pointed out, in jaundice from suppression 
the biliary acids have not been formed, and we find only the bile 
pigment in the urine; while in jaundice from reabsorption, that fluid 
contains both. 

Harley's test is as follows : " To a couple of drachms of the suspected 
urine add a small fragment of loaf sugar, and afterwards pour slowly 
into the test-tube about a drachm of strong sulphuric acid. This 
should be done so as not to mix the two liquids. If biliary acids are 
present, there will be observed at the line of contact of the acid and 
urine, after standing for a few minutes, a deep purple hue." 

After a time, in cases in which the secretory powers of the liver 
become impaired, the biliary acids disappear; and then, tyrosin and 
lencin are found in the urine. To detect these, evaporate slowly an 
ounce of the urine to the consistence of syrup, and put it away to 
crystallize. Tyrosin is known by fine stellate groups of needles under 
the microscope. Leucin, by flat circular crystalline disks, soluble in 
water but not in ether. 

Prognosis. — Acute jaundice is not very often fatal. In the U. S. 
army, of 10,929 cases only 40 died. When it lasts a month or two, 
however, as well as when acute yellow atrophy of the liver exists, 
there is always danger connected with its organic cause. The jaun- 
dice of young infants is of short duration, and almost never of serious 
consequence. 

Treatment. — When supposed to be temporary and functional, the 
great object must be to restore the action of the liver. As remarked 
already, the large accumulation of clinical experience, sustained by 
some though not by all of the physiological experiments made by vivi- 
sectors, compels me to believe that calomel and blue mass and other 
mercurials are cholagogues. If they be not so always in trials upon 
animals in health, they have proved so generally in human beings in 
cases of torpor of the liver. If obstruction be the trouble, their action 
is more doubtful, necessarily. But even then they may promote the 
solution of a recent gall-stone, if they render the bile more copious and 
liquid. 

Moderate doses of calomel or blue pill may be urged, then, gene- 
rally, during the first week or more of treatment. These maybe aided 
by saline purgatives, as sulphate or citrate of magnesia, Rochelle salts, 
or cream of tartar. After them, small doses of resina podophylli may 
be tried, if required by persistence of the disease ; or, if the bowels 
will not bear purging, extract of taraxacum. Bicarbonate of soda, 



190 DISEASES OF THE LIVER. 

taken before meals, is mildly cholagogue. But, in a case of some 
weeks' duration, slow to recover, nitromuriatic acid, 3 or 4 drops twice 
or thrice daily, will often hasten recovery very much. This I saw in 
a number of cases of malarial jaundice from the Army of the Potomac, 
in 1862. 

ACUTE YELLOW ATROPHY. 

This is a generally fatal affection, occurring most frequently in those 
who have been intemperate, or injured by venereal excesses, or who* 
have been exposed to malaria. 

Symptoms. — Beginning like ordinary jaundice, with nausea, con- 
stipation, and headache, the skin becomes intensely yellow (" black 
jaundice") ; vomiting comes on, the pulse is rapid, though variable, 
and delirium occurs. Then, with fever, and often pain in the side, the 
stomach and head are more and more disturbed. Vomiting of altered 
blood takes place ; not unfrequently also hemorrhage from the bowels. 
Petechia? appear on the skin. Prostration, tremors or convulsions, 
and coma end the history, usually in less than a week. 

Secretions. — Marked deficiency of urea in the urine, and the pre- 
sence of leucin and tyrosin in that excretion, have been remarked. 

Morbid Anatomy and Pathology. — The liver after death is 
flattened out and lessened to perhaps less than half its normal size. 
Its cut surface has a yellow color like rhubarb ; the bloodvessels are 
empty. The lobules are not distinctly marked, many of the secreting 
cells being destroyed ; in their place are masses or spots of dark bile- 
pigment, fat, and haematin. The kidneys are often found in a state of 
partial degeneration. 

Evidently atrophy, with cessation of functional action, of the liver, 
is here the cardinal fact. Is it preceded by a violently destructive 
inflammatory process ? Some of the symptoms would point to this. 
Yet, in the absence of autopsic evidence, uncommon as primary rapid 
atrophy seems to be in any organ, the precedence of inflammation 
must not be taken for granted. The cause of death seems to be 
cholaemic poisoning. 

Diagnosis. — From acute hepatitis this complaint is distinguished 
by the greater amount of jaundice, the occurrence of hemorrhage 
from the stomach or bowels, the severe headache and stupor; but, 
most of all, by the diminution of dulness on percussion over the 
hepatic region, in connection with symptoms showing violent disorder 
of the liver. The urine will also be found after evaporation to contain 
tyrosin and leucin ; sometimes in crystalline deposits. 

Treatment. — Unless in the earliest stage we are warranted in 
endeavoring to promote the normal " unloading of the portal circle" 
by purgatives, it is difficult to see any hopeful indication for treatment 
in this affection, other than palliation of fever, if there be such, by 
diaphoretics, aiding the depuration of the blood by diuretics and laxa- 
tives, and prolonging life by appropriate support. It is doubtful 
whether any cases recover from acute yellow atrophy of the liver. 



PIGMENT LIVER — CIRRHOSIS. 191 



PIGMENT LIVER. 

Frerichs and others have found after death from remittent fever, or 
in patients dying from other diseases after exposure to malarial in- 
fluence, a peculiar condition of the liver. It is steel-gray, or blackish, 
or chocolate-colored ; presenting brown insulated figures upon a dark 
ground. This change of color is due to the accumulation of pig- 
mentary deposit in the bloodvessels. 

The spleen is also somewhat similarly altered ; and so, to a less ex- 
tent, are the brain and kidneys. The blood is deficient in corpuscles, 
and contains many floating particles or masses of pigment. 

Diagnosis. — During life, examination of a few drops of blood will 
display the abundance of free pigment. The skin is sallow or dull 
yellow. Enlargement of the spleen, anasarca, albuminuria, diarrhoea 
or intestinal hemorrhage, and delirium or a tendency to stupor, may 
occur. There is but little jaundice. 

Pathology. — The scientific interest of this affection turns chiefly 
upon the proof it affords of the effect of malarial poison in disorgan- 
izing the blood-corpuscles. This is in accordance also with the re- 
markable and important influence in chronic malarial disease (as 
obstinate intermittent), of iron, as a remedy. 

Treatment. — The discovery of pigmentary degeneration or deposit 
in the blood, or the supposition of its occurrence in the liver or other 
organs, does not offer any new or special indication for treatment, 
beyond what the other conditions of the case present. The malarial 
poison is to be antagonized, and the system aided in restoring the 
disturbed organs and functions to their normal balance ; the appro- 
priate means for which ends will be considered under other heads. 

CIRRHOSIS. 

Synonyms. — Hob-nailed liver, gin-liver. 

Anatomy and Pathology. — In its commencement or first stage, 
cirrhosis is attended by some increase in the bulk of the liver ; with 
increase also of its firmness. When the disease is more advanced, 
the organ lessens in size, especially the left lobe ; the induration 
becomes aggravated. Knobs or granulations (nutmeg liver) project 
all over its surface. The capsule of the liver is always thickened. 

The character of these alterations is believed to be due to the new- 
formation of connective tissue, in the ramifications, through the gland, 
of Glisson's capsule. Bands of this material constrict the lobules, 
obstructing the bloodvessels and bile-ducts, as well as the gland-cells. 
Thus diverse effects are produced. Commonly the subdivisions of the 
portal vein are diminished in size, or obliterated ; those of the hepatic 
artery enlarged ; and those of the hepatic vein unchanged. The 
biliary ducts are at first distended by partial obstruction, causing re- 
pletion of the cells ; afterwards both .cells and ducts may be in con- 
siderable part destroyed. The color of the granulations is dark or 
pale yellow. Along with these changes, in many but not in all cases, 
fatty or waxy degeneration of the liver-structure ensues. 

Inflammation of the capsule of Glisson and its interstitial ramifica- 
tions is considered by most pathologists to be the primary element of 



192 DISEASES OF THE LIVER. 









cirrhosis. Without feeling altogether certain of the correctness of 
this view, I am unable to suggest any other to take its place, without 
entering upon a discussion too complex for our present purpose. 

Symptoms. — Nausea and indigestion, with a furred tongue and 
slight yellowness of the skin and eyes, are the earliest (of course not 
pathognomonic) manifestations of this disease. Afterwards, mostly 
with slow progress, come constipation, vomiting, emaciation, debility, 
ascites, with or without general dropsy, and enlargement of the su- 
perficial abdominal veins. This last sign is especially significant of 
obstruction of the hepatic circulation. Towards the close of life, 
hemorrhage from the stomach or bowels, delirium, coma, or convul- 
sions are apt to occur. 

Diagnosis. — From acute congestive or inflammatory affections of 
the liver the slow progress of cirrhosis readily separates it. From 
fatty and waxy liver, and from cancer, it is distinguishable, though not 
always with ease, by the continued enlargement of the organ in those 
affections; while they are also less constantly attended by dropsy and 
enlargement of the abdominal veins. The spleen is also often enlarged 
in cases of cirrhosis. This, however, occurs also when the portal vein 
is inflamed or obstructed, either by coagula or by pressure. There is 
then, however, apt to be compression of the bile-ducts, producing de- 
cided jaundice, with clay or slate-colored stools. Chronic peritonitis 
is sometimes difficult to diagnosticate from cirrhosis ; but in the former 
there is more abdominal tenderness, and less enlargement of the super- 
ficial veins. 

Prognosis. — .Recovery from cirrhosis of the liver is not to be ex- 
pected ; but its duration varies greatly, and may be favorably modified 
by regimen and treatment. 

Causation. — Although malarial influence and syphilis may predis- 
pose to it, the special cause of cirrhosis is believed to be alcoholic 
poisoning. It is one of the most common results of continued intem- 
perance. 

Treatment. — Having the hope only of palliation and delay, we 
must, most of all, prevent the persistent action of the cause, by en- 
forcing abstinence from spirituous liquors. Nourishing diet is, at the 
same time, very important. Milk, if well digested by the patient, 
meat, or concentrated liquid animal food, as beef-tea, chicken-broth, 
&c, will be suitable. The secretions must be attended to. Saline 
laxatives, especially the bitartrate of potassa, will often be useful. 
Bitters or other stomachics may be called for to relieve nausea and 
strengthen digestion. Dropsy may sometimes require tapping. 

FATTY LIVER. 

This form of degeneration is not uncommon in intemperate persons, 
or in those suffering from prolonged debility, as in phthisis. Perhaps 
its association with the latter disease is the most frequent. 

In its diagnosis, beyond the fact of enlargement of the liver, with 
smooth margin and surface, in an enfeebled constitution, unaffected by 
the symptoms of other hepatic disorders, unless it be slight jaundice, 
there is nothing positive. The change may go on undiscovered even 
by a careful observer, until after death. 



WAXY LIVER — SYPHILITIC LIVER. 193 

Anatomically, the liver-cells are gorged with oil ; their nuclei being 
destroyed or obscured. With enlargement, the whole organ presents 
a pale and flabby as well as greasy aspect ; and the latter property is 
obvious to the touch. 

There is no treatment especially appropriate to this affection, other 
than what the constitutional state will point out for itself. 

WAXY LIVER. 

Synonyms. — Amyloid, lardaceous, colloid degeneration of the 
liver. 

This is often an accompaniment of fatty degeneration ; but also 
occurs quite frequently without it. 

Anatomy and Pathology. — The waxy liver is pale or mottled in 
hue, and. when cut. smooth, hard, and dry. It is heavier than natural. 
The degeneration probably begins in the lobular ramifications of the 
hepatic artery, and extends to the secreting cells. Under the micro- 
scope these are found to have a pearly look, and to have lost their 
cell-walls and nuclei. The acini or lobules remain very distinctly 
marked out. 

Fatty degeneration may coexist with the waxy ; and hence they 
have been confounded together. The weight of the liver is modified 
(made lighter) by the presence of fatty degeneration. 

The term amyloid has been giveu to the waxy or colloid change 
because of a starch-like chemical reaction of the degenerated material. 
It is hardly to be said that the chemical discussion on this point has 
yet ended. 

Symptoms and Physical Signs. — Anaemia, emaciation, and dropsy 
(with, often, vomiting or diarrhoea, but little or no jaundice), unex- 
plained by other local or general causes, and occurring in a scrofulous, 
syphilitic, or malarial diathesis, may cause a suspicion of this form of 
degeneration. 

Examination confirms this if we also find the liver uniformly en- 
larged and firm, with at the same time enlargement of the spleen, and 
albuminuria. 

Diagnosis. — Fatty liver does not exhibit so much increase in size, 
and it is of a softer consistence upon pressure ; splenic enlargement 
and albuminuria less often attend it ; and the same is true of dropsy. 
Syphilitic inflammation of the liver differs from it in presenting promi- 
nent nodules upon the surface of the organ. 

Causation. — Syphilis is the most common predisposing cause of 
waxy degeneration. The tubercular constitution probably comes next. 
It exists most frequently in males. 

There is no especially indicated treatment for this affection. 

SYPHILITIC LIVER. 

Among the organic affections now recognized as displaying locally 
the effects of the syphilitic diathesis, is a form of chronic hepatic in- 
flammatory degeneration ; that is, inflammation followed by a specific 
organic change of structure. 

Anatomically, the liver is somewhat enlarged ; with an uneven sur- 
17 



194 DISEASES OF THE LIVER. 

face, from cicatrices alternating with nodules. This nnevenness may 
be felt upon palpation through the wall of the abdomen. The patient 
is pale, but not jaundiced ; and dropsy is not present as a symptom, 
unless from other organic causes. 

In diagnosis, syphilitic liver is to be distinguished from cancer of 
the liver by the smaller size and softer consistence of the projecting 
nodules in the former, the absence of tenderness on pressure, and, 
usually, by the signs of general syphilis ; as, the marks of cicatrized 
ulcers in the throat, copper-colored blotches upon the skin, or nodes 
upon the bones. 

CANCER OF THE LIVER. 

Mostly in middle life, but occasionally even in the young, cancer of 
the liver occurs, and has a more rapid progress than most cancers. 
The symptoms are, pain in the right side and shoulder, with tender- 
ness in the right hypochondriac region, disorder of the stomach and 
bowels, rigidity of the abdominal muscles (especially the rectus), 
debility, emaciation, a cachectic aspect, and ascites or general dropsy. 
There is usually little or no jaundice. 

Physical exploration shows dulness on percussion below and above 
the usual limits of the liver ; and, on palpation, irregular prominences, 
hard in most cases, but sometimes, in encephaloid cancer, soft and 
elastic. The enlargement may become very extensive ; and then all 
the effects of pressure, upon the portal vein, etc., are observed. 

This disease is always fatal ; affording no room for other than merely 
palliative treatment. Its duration is often less than six months : 
seldom more than a year. 

HYDATIDS. 

These are elastic tumors, consisting of cysts, developed around 
echinococci. The latter are the larvae or immature progeny of a 
taenia ; they are found not only in the liver, 1 but also in the brain, 
muscles, bones, ovary, uterus, kidneys, lungs, heart, spleen, etc. The 
sac or cyst grows slowly, and may exist for years without great dis- 
turbance of the health. If any symptoms occur, they are indigestion, 
debility, and dropsy. 

Hydatids are discovered upon inspection and palpation ; the liver 
being considerably enlarged, so as to press up the diaphragm and 
right lung, or to sink far down into the abdomen. On percussion, 
besides an irregular line of extended dulness, a peculiar jelly-like 
vibration is sometimes perceptible by the finger used to percuss upon. 
If the tumors be so near the surface and so evidently elastic as to 
warrant the operation of exploration with a grooved needle, the fluid 
drawn out will be very characteristic. It is colorless, of specific 
gravity not much above that of water (1007-1010), and is free from 
albumen ; it contains a large amount of chloride of sodium. 

Sometimes the entozoa within the cyst die, and the sac collapses 
and disappears. In other cases it bursts and is discharged into the 

1 Of 508 cases of hydatids, Cobbold and Davaine found the liver to be affected 
in 216. 



DILATATION OF THE GALL-BLADDER. 195 

alimentary canal, the lungs, or externally through the abdominal walls. 
Slow recovery may then be anticipated. Danger always exists, how- 
ever, that the hydatids may open into the pleural or peritoneal cavity, 
producing pleurisy or peritonitis. In a few instances suppurative in- 
flammation occurs in the cyst. 

In the treatment of hydatids, some physicians have been disposed 
to confide in the supposed power of iodide of potassium, and of chlorate 
of potassa, taken internally, to cause the absorption of the fluid of the 
cyst, and thus destroy the parasite. But the evidence is not such as 
to justify such confidence. 

Very large and superficial hydatids may, when the diagnosis is clear, 
be tapped, with at least temporary relief to the patient. Should this 
be safely done without cure, it may be repeated, and then a gum-elastic 
tube may be introduced and retained in the opening, so as by drainage 
to induce the shrinking of the cyst and thus the destruction of the 
echino coccus. Dr. Pavy reports success in one case with injection of 
male fern into a hydatid cyst of the liver ; its anthelmintic or parasiti- 
cide power seeming to be thus shown. 

TUBERCLE OF THE LIVER. 

Primary tuberculization of the liver is never met with. In patients 
dying with phthisis, not unfrequently yellow or gray miliary tubercular 
deposits are found scattered over the gland ; they rarely soften, but 
sometimes small vomicae are met with. It is of course necessary to 
be aware of the possible existence of such formations, in the considera- 
tion of the morbid anatomy of the liver. 

DILATATION OF THE GALL-BLADDER. 

This may be produced by obstruction of the gall-duct or the common 
bile-duct, or, more rarely, by a morbid formation of serous fluid within 
it, allied to a local dropsy. The diagnosis of this may be important, 
as it may readily be confounded with hepatic enlargement. It is to be 
distinguished from cancer by the great amount of jaundice (in most 
cases), the previous occurrence of gall-stone colic (also not invariable), 
and the more uniform and softer character of the swelling. From 
hydatids the same signs, except the softness of the tumor, are distinct- 
ive : and the latter grow much more slowly. 

For the treatment of dilatation of the gall-bladder, the remedies 
suitable for obstruction of the biliary ducts will be appropriate. 
Surgical interference would, in any case, be very bold practice. 

AFFECTIONS OF THE SPLEEN. 

These are necessarily treated of at length in systematic treatises. 
It will be enough for our purpose to say a very few words of them. The 
spleen is commonly enlarged in intermittent, remittent, and typhoid 
fevers, and in leucocythcemia ; sometimes, in pregnancy (Simpson). 
Rupture of the spleen, causing death, has been several times reported. 
Such an affection could scarcely (*. e., rupture of the spleen) be diag- 
nosticated during life. 

Enlargement of the spleen is readily ascertained by inspection and 
palpation. It often increases and diminishes, during and between the 



196 DISEASES OF KIDNEYS AND BLADDER. 

paroxysms of intermittent (ague-cake). Piorry asserts its rapid 
diminution under cinchonization. Other affections of the spleen 
(inflammation, tubercle, hydatids, &c.) are so generally difficult of 
diagnosis as to have chiefly a post-mortem interest ; and they present 
no clearly recognized indications for treatment. 



AFFECTIONS OF THE KIDNEYS AND BLADDER. 

CONGESTION. 

Causation. — Under exposure to cold, overdoses of cantharides or 
turpentine, or the disturbance belonging to different inflammatory 
and febrile complaints, active renal congestion may occur. Passive 
congestion is more common in heart-disease, or pulmonary obstruc- 
tion, as in pleuritic effusion or emphysema, or when pressure impedes 
the circulation of the renal veins or vena cava, as in pregnancy or 
abdominal tumors. 

Symptoms. — Pain in the lumbar region, sometimes with tenderness 
on pressure on each side of the spine. Scanty urination, the fluid 
being high-colored, sometimes bloody, or containing albumen. Certain 
cases exhibit under the microscope fibrinous casts. 

Diagnosis. — It is only occasionally difficult to distinguish this con- 
dition from Bright's disease. Active congestion begins abruptly, 
under a recognizable cause. Passive congestion shows a dependence 
upon some other organic affection, and, although variable, is not pro- 
gressive. They are thus distinguishable from advancing and more or 
less permanent disease of the kidneys. 

Treatment. — For active congestion, cupping the lumbar region, 
abstracting blood according to the state of the patient. Purgation, 
by castor oil or citrate or sulphate of magnesia. Then, the warm 
bath or hip-bath, continued for some time. 

URJEMIA. 

Definition. — The retention in the blood of the material which it is 
the function of the kidneys to excrete ; from the suppression of their 
action. 

Symptoms. — When well marked, headache, dimness of vision, 
vomiting, diarrhoea, convulsions and stupor; ending in fatal coma. 

Pathology. — The question as to what is the immediate toxic agent 
in uraemia is not yet fully determined ; i. e., whether it is urea, or an 
ammoniacal educt from its decomposition in the blood. In the 
absence of demonstration of the latter, the former is most probable. 
A further view has recently been urged ; that it is unchanged creatin, 
creatinin, and other extractives, that contaminate the blood. . 

Treatment. — This must vary with the circumstances of the pro- 
duction of the suppression ; but the great indication is to depurate the 
blood — by the kidneys if they can be restored to action, and by the 
aid or substitution of the bowels and skin. For this end, the warm 
bath, or the hot air, or warm vapor bath may be of great service. So 
may cupping or counter-irritation by mustard or tincture of iodine 



NEPHRITIS — BRIGHTS'S DISEASE. 197 

over the small of the back. Saline cathartics, even hydragogues, 
may be given to such patients as have strength to bear them ; as cream 
of tartar, Epsom salts, elaterium, or croton oil ; the last two most rarely. 
Lemonade drunk freely is often one of the best of diuretics. Others 
will be mentioned hereafter, in connection with dropsy. 

NEPHRITIS. + v 

In the present state of urinary pathology, it is common to merge 
the topic of inflammation of the kidney (except suppurative pyelitis) 
as distinct from active renal congestion, — in Bright's disease. If this 
be questionable as a matter of pathological system, it has at least prac- 
tically no disadvantage ; as the symptoms of nephritis are included in 
one or other of the affections named ; and so is its treatment. We 
may submit therefore to the usage of authority upon this point, with- 
out hesitation. The symptoms of acute pyelitis (inflammation of the 
pelvis of the kidney) are essentially those of renal congestion, inten- 
sified ; with tenderness on pressure over the kidney, and fever, until 
suppuration is established; then, purulent discharge for a variable 
time from the kidneys. (See Pyonephrosis). Before pus appears, 
blood, in small quantity, mucus, and renal epithelial cells may be found 
in the urine. A tumor in one of the lumbar regions may precede for 
a while the escape of the pus. 

BRIGHT' S DISEASE. 

Definition. — Albuminuria; dependent upon structural change in 
the kidneys ; or, to speak, perhaps, more correctly, disease of the 
kidney, characterized by albuminuria and dropsy. 

Varieties or Stages. — Authorities differ as to the discrimination of 
these. Bright believed there were three varieties. Dr. G. Johnson 
asserts two, — the desquamative and non-desquamative nephritis. 
Frerichs considers them to be stages of the same affection, and admits 
three stages, essentially, of hyperemia, exudation, and degeneration. 
Anatomically, we have the large, smooth, white kidney, the small, 
smooth kidney, the granular uncontracted kidney, and the granular 
contracted kidney. We may safely follow Roberts, in dividing Bright's 
disease, first, into acute and chronic. The latter is then divided into, 
1. Causes which have lapsed from the acute state (smooth, white, 
generally large kidney) ; 2. Cases chronic from the beginning (granular, 
red, contracted kidney) ; 3. Cases associated with waxy or amyloid 
degeneration of the kidneys. 

Causation. — Bright's disease is one third more common in males 
than in females. The greatest number of cases occurs between the 
ages of 45 and 65. Acute Bright's disease is most often produced by 
cold and dampness ; next, by scarlet fever, pregnancy, or violent in- 
temperance. The acute form is most common in early life. 

Chronic Bright's disease is also greatly promoted by exposure to 
cold and wet ; and is caused moreover by abuse of spirituous liquors, 
very often. Other predisposing causes are gout, constitutional syphilis, 
and affections of the bladder and urethra. 

17* 



198 DISEASES OF KIDNEYS AND BLADDER. 

Symptoms.— Acute Bright's Disease.— After exposure to cold, or 
a drunken fit, or scarlet fever, the patient is seized with chilliness, 
headache, nausea, vomiting, pain in the back and limbs, checking of 
perspiration, and oppression in breathing. Fever follows ; and the 
face, trunk, and limbs become puffy with anasarca. Effusion may 
also occur into the pleura or peritoneum. 

The urine is scanty, heavy, and dark in color, from the presence of 
blood ; and very albuminous. The disposition to void it occurs more 
frequently than during health. The deposit from it, under the micro- 
scope, shows blood-corpuscles, loose renal epithelium, free nuclei, tube- 
casts, and shapeless masses of fibrin and debris. 

After one, two, or three weeks, or even a longer period, the attack 
proceeds to one of three terminations ; recovery, death, or lapse into 
the chronic state. Death results through uraemia, or from secondary 
pneumonia, pleurisy, peritonitis, pericarditis, — or hydrothorax, oedema 
of the glottis, hydrocephalus, or ascites. Probably two-thirds or more 
of the cases of acute Bright's disease recover. 

Treatment. — Cupping the loins, hot water or hot air or " blanket'' 
bath, active purging, as with cream of tartar and jalap, or citrate of 
magnesia, and diaphoretics, as citrate of potash or liquor ammon. 
acetat. Mercury is not recommended. The diet should be liquid 
and simply nutritious. 

Chronic Bright's Disease. — This approaches so slowly as seldom 
to be detected until after the lapse of months or years. Gradual loss 
of strength, pallor or puffiness of the face, shortness of breath, and 
frequent disposition to urinate, are early signs of it. But they are 
not always present; the denouement of* the disease may be by a con- 
vulsion, oedema of the lungs, amaurosis, or some violent local inflam- 
mation. 

Symptoms of a well-marked case (not all present in every instance) 
are : albuminous urine, deposits of tube-casts and renal epithelium, 
dryness of skin, frequent micturition, especially at night, general 
dropsy, or local effusions into the cavities, indigestion, anaemia, uraemic 
effects (headache, dizziness of sight, convulsions, coma, vomiting, 
diarrhoea), enlargement of the heart, and secondary inflammations. 
Bronchitis is especially common. 

The progress of the case is usually interrupted by exacerbations and 
intervals ; each fresh attack leaving the patient manifestly worse than 
before. Such attacks much resemble acute Bright's disease; they are 
sometimes referred to known causes ; the intervals may last weeks, 
months, or even years, 

In prognosis, the tendency is always toward a fatal result. About 
one-third die of uraemic poisoning. A considerable number die of 
local dropsical effusions. One-fifth from secondary pneumonia, peri- 
carditis, or pleurisy. The rest, by exhaustion from anaemia, indigestion, 
and anasarca, or the complications of apoplexy, cirrhosis, phthisis, 
intestinal ulcerations, &c. 

Diagnosis. — The presence of albumen in the urine, with dropsy, 
not ot sudden origin or brief duration, is pathognomonic of this 
affection. The tests for albumen, by heat and nitric acid, are readily 
applied. The microscope will show also free renal epithelium and 
tubular casts in the urine; in advanced cases, the casts are sprinkled 



bright's disease. 199 

with oil-dots. The solids of the urine, especially the urea, are reduced 
below the normal amount. 

Pathology. — Degeneration of the structure of the kidney induces 
albuminuria, by allowing the serum of the blood to pass almost un- 
changed through the cortical substance into the tiibuli uriniferi. 
The deficiency of urea is due to the same impairment of secreting 
power. The consideration of the different varieties of renal degene- 
ration would be too complex a subject for these pages. The reader 
is referred for it to the standard treatises on the subject. 

Treatment. — The indications in every case of Bright's disease are — 
1. To hinder the progress of structural change in the kidney ; 2. To 
prevent uraemia and secondary inflammation ; 3. To palliate concomi- 
tant S} T mptoms or states, as anaemia, dropsy, dyspepsia, &c. 

Regimen or hygienic management is of the utmost importance for 
the first of these ends. Avoidance of exposure to cold, wet. or great 
fatigue ; the reform of intemperance, if it has existed, or of other ex- 
cesses, — will be indispensable. Clothing should be sufficiently warm, 
with flannel next to the skin. Bathing frequently, at such temperature 
as is borne without chill or relaxation, is to be recommended. The 
bowels should be kept regularly open. Nourishing diet, of which milk 
may generally be part, is of consequence. 

Iron will do more good than any other medicine, unless it be cod- 
liver oil in those of strong stomach. They may be very well combined. 
The tincture of the chloride of iron is as good as any other chalybeate, 
as a general rule. With some the citrate of iron in solution, or the 
carbonate or the iodide, will agree more readily. 

It is very doubtful whether astringents ever check to advantage the 
waste of albumen through the kidneys. If any be worth the trial, it 
is ammonio-ferric alum. Counter-irritants over the kidneys, unless of 
the mildest character (tinct. iodin., emplastr. picis, <fcc), will not do 
any important good in chronic Bright's disease. 

For the dropsy, warm baths and hydragogue cathartics are advised. 
Of the latter, cream of tartar and jalap, together, are the favorites : 
2 or 3 drachms of the bitartrate with 10 to 20 grains of jalap two or 
three times a week. If serious dropsical accumulation threaten life, 
elaterium (gr. £ or \ every four hours, in pill, till it acts) may be given. 
But it is a decided mistake to harass the patient constantly with ex- 
hausting purgation. It is to be remembered that it can act only as a 
'palliative, removing part of the effects of the malady, not the disease 
itself. 

If the warm bath do not agree, or fail to produce diaphoresis, those 
who have access to it should try the hot air bath, at 130° to 150° Fahr. 
This rarely fails to produce free perspiration. For weaker invalids, 
the vapor bath is available. 

Of diuretics, acetate of potassa, spirit of nitrous ether, and infusion 
or compound spirit of juniper will be the least likely to disappoint. 
But all will not unfrequently fail. 

Then we have as a resource (where tapping for ascites is not de- 
manded) for the relief of great oedema, the use of incisions with a 
lancet, or needle, in the swollen legs and feet. I prefer a number of . 
small incisions with an abscess lancet, plunged through the skin of the 
calf and dorsum of the foot. It is possible that erysipelas may follow; 



200 DISEASES OP KIDNEYS AND BLADDER* 

but this danger will be lessened by repeated warm sponging of the 
limbs, washing them with diluted glycerin, or inunction with lard or 
cold cream. 

The complications of Bright's disease must be treated according to 
their own indications, on general principles, — bearing in mind always 
the degenerative and asthenic tendencies belonging to the malady 
itself. 

LITHIASIS. 

Definition. — The formation of calculous deposits (gravel or stone) 
in the kidneys or bladder. 

Causation. — Stone is, by statistics, nearly ten times as frequent, or 
at least as fatal, in the male as in the female. It destroys life most 
often after fifty years of age ; but is far from uncommon in early life, 
even under five years. Locality has something to do with the causa- 
tion of stone and gravel. They are common in England, Iceland, 
France, and Egypt, and uncommon in Sweden, Norway, and Austria. 
I n this country they are not rare ; the greatest number of cases pro- 
bably occurs in the State of Kentucky. 

Varieties. — Of these a sufficient account (for our purpose) has been 
given in the first part of this book. (See Semeiology.) 

Diagnosis. — Examination with the sound is indispensable to deter- 
mine the presence of a calculus in the bladder. The characters of the 
urine will aid in determining its nature. If the urine be decidedly 
acid, the stone is probably uric acid or oxalate of lime, or a combina- 
tion of both. If alkaline from fixed alkali, it is either phosphate or 
carbonate of lime (both rare). If alkaline from volatile alkali, what- 
ever its nucleus or central part, the surface must be formed of the 
ammonio-magnesian phosphate and phosphate and carbonate of lime. 

Pain in the bladder and in the back, and pain or itching in the glans 
penis, retraction of the testicle, and interruption in the flow of urine, 
occurring at times suddenly, are the most prominent symptoms of 
stone in the bladder. 

Gravel consists of small calculous concretions, which may be voided 
through the urethra. Pain in the back, with chilliness followed by 
fever, commonly precedes an attack, or u fit of the gravel ;" to which 
some persons are subject whenever they take cold or suffer from indi- 
gestion. Extreme pain may attend the transit of a small calculus 
through the ureter from the kidney to the bladder. 

This troublesome affection (gravel) in the large majority of instances 
is owing to undissolved uric acid and the urates. 

Treatment of Gravel. — Under the indication suggested by the last 
mentioned fact, the dilution and alkalization of the urine are called 
for. The small calculi often irritate the bladder painfully, inducing 
sometimes spasmodic retention of urine. Free draughts of a demul- 
cent liquid, as flaxseed tea, will do good ; and the secretion may be 
made more copious, and thus dilute, and the solution of uric acid and 
its compounds promoted, by the administration of spirit of nitrous 
aether and bicarbonate of soda, in tolerably full doses, three or four 
times a day during the attack [F. 122]. The agonizing pain from the 
passage of a calculus through the ureter will require anodyne treat- 






DIABETES INSIPIDUS. 201 

merit, by opium, or inhalation of ether or nitrous oxide, and relaxation 
by the prolonged warm bath. 

Prevention. — Any one inclined to gravel (one sign of which ten- 
dency is a pink stain in the urinal left after the urine has been thrown 
out) should avoid highly animalized or otherwise stimulating food. 
The urine may be kept dilute by taking a tumblerful of water two 
hours before dinner, and another at bedtime. The skin must be kept 
open by baths, frictions, and sufficiently warm clothing. Exercise 
will generally be beneficial in prevention. If acidity in the urine be 
positive, small doses of the bicarbonate of soda, or of the acetate, 
citrate, or carbonate of potash may be taken daily. 

Treatment of Calculus. — Although the result of much experimenta- 
tion had been, until of late, to turn over the management of stone to 
the operative surgeon, new reason has been given for hoping for some- 
thing in its relief without the knife. Dr. W. Roberts has, in this, made 
some very promising observations and experiments. 

Urinary calculi may be, practically, divided into those soluble in 
alkalies and those soluble in acids. Of the first, there are uric acid 
and its salts, and cystine ; of the second, phosphatic and mulberry 
calculi. Solvent treatment affords hope only by alkalizing the urine, 
in cases of the former, by medicines taken by the mouth, and injecting 
acid solutions into the bladder for direct action upon mulberry calculi 
and the phosphates. 

Very weak solutions of acetate or citrate of potash, taken often, 
alkalize the urine most efficiently, according to Dr. Roberts' experi- 
ments. He does not encourage the hope that large or old calculi can 
ever be so dissolved. Dilute nitric acid is proposed for injection into 
the bladder for the solution of phosphatic calculi, especially after their 
being broken down by the lithotrite ; and Sir B. Brodie and Mr. 
Southam have carried this procedure, in two cases at least, with suc- 
cess into practice. 

DIABETES INSIPIDUS. 

Definition. — Excessive discharge of almost colorless urine, of light 
weight, containing neither sugar nor albumen ; with polydipsia or 
excessive thirst. Synonym, polyuria. 

Causation. — This is various, and generally obscure. More males 
have the affection than females. It is most common between five 
and thirty years of age. Blows on the head, intemperance, cerebral 
disease, and exposure to cold or drinking cold fluids while heated, are 
among the supposed causes. 

Pathology. — This, too, is various or undetermined. In some in- 
stances degeneracy or atrophy of the kidneys has been found after 
death ; in others, renal congestion. Very probably the degeneration 
may be secondary. Probably the immediate cause of the excessive 
urination is dilatation of the capillary vessels of the kidneys ; this 
having its origin in some remote agency which disturbs the ganglio- 
nervous influence that controls the circulation. 

Symptoms and Course. — Often beginning suddenly, the amount 
of water passed may reach ten or twenty quarts per diem. Thirst is 
intense, and withholding liquids does not arrest the polyuria. The 



202 DISEASES OP KIDNEYS AND BLADDER. 



skin becomes dry and harsh. Debility and emaciation attend, if the 
attack is prolonged. 

The duration of the complaint varies from a few weeks to many 
years — or a lifetime. It is sometimes congenital. An intercurrent 
attack of febrile or inflammatory disease sometimes suspends, or even 
cures it. 

Treatment. — This has been, so far, tentative only ; no specific is 
known for it. Nitrate of potassa, valerian, ergot, iron, alum, lime- 
water, tannic and gallic acid, creasote, and bromide of potassium are 
the medicines mast worthy of trial. Blistering the nape of the neck 
has also been suggested. 



u 



DIABETES MELLITTJS. 



Synonym. — Glycosuria. 

Definition. — Excessive urination, with the presence of sugar in the 
urine. 

Causation. — Twice as many men as women have this disease. It 
is most frequent among young and middle-aged adults; the mortality 
from it being greatest from fifteen to fifty-five. It is more common 
in cities and manufacturing districts than in the open country. Oc- 
casionally it is hereditary. 

Exciting causes appear to be, exposure to cold and wet ; drinking 
cold water largely when heated ; excessive use of saccharine food ; 
intemperance ; violent emotion ; febrile diseases ; and organic affec- 
tions and injuries of the brain and spinal cord. 

Symptoms and Course. — Beginning insidiously, with malaise and 
slight loss of flesh, urination becomes excessive, with corresponding 
thirst, and very often bulimia or excessive appetite ; emaciation is 
progressive ; the skin is harsh and dry ; the tongue, glazed, and fur- 
rowed, the mouth clammy; the sexual and mental powers fail by 
degrees. Lastly, hectic fever, oedema of the limbs, diarrhoea, and 
often all the symptoms of pulmonary consumption terminate the case. 

Complications. — Tuberculization of the lungs occurs in nearly half 
the cases of diabetes mellitus which last over a year or two. Inflam- 
mations of an asthenic type are common in all the organs. Boils and 
carbuncles are very frequent. Gangrene of the lower extremities has 
been several times observed. Amblyopia (obscure vision) is present 
in about one-fifth of the cases. Cataract generally forms in cases of 
long standing ; but uiay be absent altogether in those of less than two 
years' duration. The endosmotic theory of diabetic cataract, suggested 
by the production of opacity of the lens in frogs by immersion in a 
saccharine solution, or injecting the same into the cellular tissue, is of 
doubtful application. Objections to it are, the temporary nature of 
the saccharine cataract in the frog, the occasional occurrence of dia- 
betic cataract in one eye only, and the late period at which the symp- 
tom occurs in the disease. 

Morbid Anatomy and Pathology. — Much remains to be done 
before the pathology of diabetes can be said to be ascertained. In 
about half of the cases, only, some degree of renal alteration is found. 
Physiological facts and experiments, in regard to the " glycogenic 
function of the liver," point to that organ as the probable seat of the 



be 



DIABETES MELLITUS. 203 

disorder. Other observations, as to the production of diabetes in 
animals by injuring the medulla oblongata or the base of the brain, 
are also suggestive. But, although in some instances autopsic inspec- 
tion has agreed with such expectations, in many other cases it has 
failed to confirm them. The true theory of diabetes therefore re- 
mains for the future to discover, or, at all events, to complete. 

The most plausible hypothesis, certainly, is, that, under disturbed 
innervation, the liver modifies its ordinary assimilative process so as 
to confiscate (to use a bold figure) most of the carbohydrogenous 
material derived from the alimentary canal through the portal vein, 
and convert it into glucose or diabetic sugar, which is then eliminated 
by the kidneys. 1 

Diagnosis. — The detection of sugar in the urine, not temporarily, 
but for a considerable time, is of itself sufficient to make out the case. 
The principal modes of testing saccharine urine have been given in 
another part of this book. (See Semeiology.) 

Prognosis. — Recovery is not impossible in diabetes ; but a large 
majority of cases end in death. Amelioration — keeping the disease 
in abeyance — is often an attainable end. The younger the patient in 
whom the disorder begins, the less ultimate hope. In old persons 
glycosuria seems more often compatible with tolerable health for a long 
time. Cases traced to mental emotion or to injuries are somewhat 
more hopeful than those of indistinct origin. 

Amblyopia, cataract, and albuminuria, as well as phthisical symp- 
toms, mark the case as incurable. Considerable diminution of the 
sugar, or of the water, passed, is always a favourable prognostic. 
But the diabetic patient is much more liable than others to those 
inflammatory complications which, on slight exposure, may hasten the 
termination of life. 

Treatment. — No direct control over the sugar-forming process in 
the body has yet been obtainable by medicine. But, although it 
would seem that simply diminishing the formation of sugar by with- 
holding material for it ought not to be expected to do much good, it 
does prove beneficial. The most important measure yet devised in 
the management of diabetes is, the prohibition of sugar and starch, 
and of everything which can yield them, as food. Bread, except 
bran bread, which is almost free from starch, potatoes, and nearly all 
vegetables and fruits must be excluded. The safe exceptions are!! the 
cabbage, broccoli, onions, spinach, celery, and lettuce. Of animal 
diet, milk and liver are forbidden articles. All meats, eggs and butter, 
and jellies, are allowable. Gluten bread is made in France, on Bou- 

1 It seems to be established that a natural product of the liver is an amyloid 
material (hepatin, liver dextrin) ; whether Bernard's view, of the normal des- 
tiny of this being its constant conversion into sugar (and subsequent combustion 
by oxidation in the blood) be correct, or rather that of Pavy, that such con- 
version is always morbid, or post-mortem. Artificial glycosuria may be pro- 
duced in animals by puncturing the floor of the fourth ventricle of the brain, 
impeding respiration, thrusting needles into the liver, obstructing the abdo- 
minal venous circulation, injecting acid into the veins, poisoning with strych- 
nia, and woorara, and chloroform or ether inhalation. Dr. McDonnell has 
lately proposed a new theory ; that " glycogen" normally in the liver combines 
with nitrogenous matter derived from food, to make plastic material for tissue ; 
and that this process is interrupted or arrested in diabetes. 



204 DISEASES OF KIDNEYS AND BLADDER. 

chardat's plan, without starch, inflated by machinery with carbonic 
acid or compressed air. Tea or coffee may be sweetened with glycerin 
(chemically pure, as Bower's or Price's). Spirits, wines and beer 
should be avoided unless called for by positive weakness ; if that exist, 
the least saccharine should be preferred, as sherry, claret, or whisky, 
in minimum quantities. There is no advantage in restricting the 
amount of water taken to quench thirst. Variety of diet, of course, 
within the prescribed limits, is important, to prevent disgust and loss 
of appetite. 

Of medicines, hone have been yet shown to do much service in 
checking the disease. The most positive influence in diminishing the 
diuresis belongs to opium ; but this does not appear to interfere with 
the progress of the disease. Yarlous drugs have been tried, and lauded 
greatly by different users ; but their effects will not bear scrutiny with- 
out disappointment. Among them the most prominent are alkalies, 
yeast, rennet, pepsin, iron, quinine, creasote, alum, iodine, nitric acid, 
turpentine, and the inhalation of oxygen. Even free ingestion of sugar 
has been fairly experimented with ; but in vain. A therapeutic remedy 
for diabetes remains to be discovered. 

HYDRONEPHROSIS. 

Definition. — Kenal dropsy ; dilatation of the kidney from obstruc- 
tion of the ureter. 

Causation. — Quite a number of the cases recorded have been con- 
genital, from anatomical malformations. Calculus in the ureter is the 
most frequent post-natal cause ; but other mechanical obstructions, 
from pressure, may occur. 

Diagnosis. — Intumescence of the abdomen, usually upon one side, 
in the hypochondriac, umbilical, and iliac regions, with a soft undu- 
lating feel, an outline often lobulated, and fluctuation as well as dulness 
upon percussion, can, in the male at least, only indicate either hydro- or 
pyonephrosis. The symptoms may be almost null, if only one kidney 
be affected. When both are so, uraemia finally results. The tumor is 
commonly quite painless, and not tender upon pressure. This affection 
is, however, quite rare. It may be fatal, by uraemia, or bursting of the 
sac into the abdomen ; but it has in a number of cases existed for many 
years. 

Treatment. — Manipulation, kneading gently, day after day, has 
sometimes succeeded in dissipating the renal distension. Nothing 
else should be attempted, unless life is endangered by the pressure of 
the tumor, or by uraemia. If it be so, tapping is justifiable; and it 
has been repeatedly performed with success. 



PYONEPHROSIS. 



This differs from the last-named affection in the production, under 
similar circumstances, with more or less inflammation, of suppuration 
of the kidney. The symptoms are therefore more active, and the 
prognosis more grave. Rupture of the sacculated kidney, into the 
colon, duodenum, or peritoneal cavity, is common, and is nearly always 
fatal. Renal abscess may occur, also, from ■' purulent infection," and 
from embolism. Such an abscess may find escape for its contents 



3er 



TUBERCLE OF THE KIDNEY. 205 

externally ; any appearance of such a tendency should be encouraged 
by poulticing, and, in fit cases, by incision and evacuation. 

CANCER OF THE KIDNEY. 

Primary cancer of the kidney is. though rare at any age. most 
frequent in early childhood. Of adults, males have been the most nu- 
merous subjects of it. Secondary renal cancer may attend any case 
of the cancerous cachexia, without materially modifying its history. 

The kind of cancer affecting the kidney is nearly always the ence- 
phaloid; called, when highly vascular, fungus hasmatodes. It always 
begins in the cortical substance. The tumor is generally large, and 
sometimes enormous; reaching, in one case (Roberts), 31 pounds. It 
is exceedingly rare for both kidneys to be affected. 

Diagnosis. — An abdominal tumor, with copious hematuria repeated 
at irregular intervals, is almost certain to be cancer of the kidney. 

Beginning between the ribs and the crest of the ilium on one side, 
the tumor grows forwards, upwards, and downwards, so as to fill in 
some cases the whole belly. The colon, in this as in all renal tumors, 
lies in front of it; sometimes also a part of the small intestine. Ex- 
cept over the intestine, percussion resonance is dull. 

The swelling is smooth or irregularly lobulated; now and then a sort 
of fluctuation, and in one instance pulsation, have been observed in it. 
It is fixed in its position. 

Bloody urine, usually profuse hemorrhage, is present in about half 
the cases. No other tumor has this symptom attending it. 1 Its occur- 
rence is, therefore, pathognomonic. The discovery of cancer-cells in 
the urine by the microscope is of course still more positive ; but this 
sign is very often absent ; and the cells are not at all easy of identifica- 
tion when they occur. 

Pain mostly, but not always, attends cancer of the kidney ; it is 
sometimes of great severity, shooting down the ureter to the thigh. 
Tenderness on pressure seldom exists. Variable symptoms are those 
of disorder of the stomach and bowels. Emaciation, and anasarca, 
show the exhaustion which precedes death. 

The duration of cancer of the kidney, in children, averages seven 
or eight months ; in adults, over two years. This is a longer period 
than that of any other visceral cancer. 

In treatment, as in other malignant diseases incapable of safe extir- 
pation or cure, the judicious management of regimen, and of anodynes, 
is all that is possible. 

TUBERCLE OF THE KIDNEY. 

This may be either primary or secondary. Of all tuberculous sub- 
jects, the kidney is found to contain such deposits in from five to six 
per cent. Among tuberculous children, in from fifteen to sixteen per 
cent. Most of these however were secondary cases. 

The symptoms of primary renal tuberculization are, dull lumbar 

1 Roberts mentions one case of great enlargement of the spleen with haema- 
turia. 

18 



206 DISEASES OF KIDNEYS AND BLADDER. 

pain, frequent micturition, the urine being at first turbid or slightly 
bloody, afterwards purulent ; emaciation, and hectic fever. Almost 
always other organs, especially the lungs, become also tuberculous ; 
merging the case into one of complicated phthisis. The bowels are 
very frequently implicated. Death occurs mostly from exhaustion. 
If both kidneys are affected, it may be from uraemia. 

The duration of the affection varies — from a few months to two or 
three years. 

Diagnosis. — Only after softening of the tubercle can it be positively 
proved to exist. Then, the abundantly purulent urine is found upon 
microscopic inspection to contain also " granular debris, sometimes 
with tuberculous matter (insoluble in acetic acid) shreds of connec- 
tive tissue, and beautiful meshes of elastic fibres from the cast-off 
patches of disintegrated mucous membrane. " Great debility and 
emaciation, with hectic fever, confirm these signs. The absence of 
tumor, and of hematuria, distinguish renal tuberculization from 
cancer. 

Treatment. — Here, again, we must confess the deficiency of our pre- 
sent therapeutics. Indications exist, essentially the same as in phthisis 
pulmonalis ; to the consideration of which we may refer the reader. 

HYDATIDS OF THE KIDNEY. 

These are more rare than hydatids in the liver or lungs ; but more 
frequent than in other parts of the body. 1 The left kidney is most 
often affected. 

In a majority of cases the cyst formed by the echinococcus opens into 
the pelvis of the kidney. The hydatids then, in part or wholly, are 
discharged by the urethra. They may however, also, or instead, burst 
into the stomach, intestines, or lungs. 

If no such vent occurs, a tumor is formed in the side (with the 
colon always in front of it) which has a more or less distinct fluctua- 
tion, and, sometimes, the "hydatid fremitus" or vibration to the touch. 

The discharge of the contents of the cyst allows the discovery, in 
some cases, of entire vesicles ; in others, of a detritus, in which the 
microscope detects echinococcus-hooks, laminated shreds, and oil 
particles. 

This discharge is apt to be recurrent or paroxysmal ; at intervals 
varying from a few weeks to one or more years. Before it occurs, 
chills, nausea, hiccough, and colicky pains often exist ; relieved by the 
passage of the vesicles. These, while in the bladder, may cause pain, 
irritation, and retention of urine. 

After every such an escape, the size of the tumor may be lessened 
for a time. A vesicle detained in the ureter may, by obstruction, 
induce a hydronephrosis, adding to the hydatid tumescence. 

Prognosis. — This is more favorable than in any other seat of hy- 
datids, except the uterus; because of the comparative facility of their 
evacuation. When, however, no escape by the kidney and ureter is 

1 According to Davaine, the order of relative frequency is as follows : liver, 
lungs, kidneys, pelvis, brain, bones, parietes of the body, heart, and orbit of 
the eye. 



CYSTITIS. 20f 

effected, the tumor may become so large as to encroach seriously upon 
other parts ; or the cyst may suppurate (pyonephrosis) and form a 
large and dangerous abscess. 

Treatment. — Oil of turpentine, iodide of potassium, chlorate and 
nitrate of potassa, taraxacum, and other medicines, have been asserted 
by different observers to promote the death and discharge of echino- 
cocci. Whether the "post hoc" was "propter hoc" in these cases, 
larger experience (which ought always to be recorded) will show. 
Electro-puncture has been tried for the same end ; but without proof 
of success. 

Hydatid colic (passage of vesicles through the ureter) may be 
treated like that from calculus, by the warm bath and opium. Irrita- 
tion of the bladder, or obstruction causing retention of urine, will 
require rest, demulcent drinks (flaxseed infusion), and, sometimes, the 
catheter. Even in the urethra the escape of the vesicles may be ob- 
structed, and sometimes may require to be aided by pressure for their 
dislodgment. 

A closed renal hydatid tumor, when clearly diagnosticated, and 
itself endangering life, may be (after exploration by the needl e 
trocar) punctured ; especially if it project behind. When in front, 
Recamier's plan is preferred by some surgeons, of applying caustic 
potash repeatedly to cause adhesion of the peritoneum to the sac 
before making the incision. Safer than this, and in at least one case 
successful, is repeated puncturing with the needle trocar, at intervals 
of a few days. 

CYSTITIS. 

Definition. — Inflammation of the bladder. 

Varieties. — Acute and chronic; idiopathic, traumatic, secondary. 

Causation. — Blows or other injuries; the presence of gravel, or a 
calculus, or hydatid vesicles from the kidney ; irritating diuretics ; 
or decomposing urine retained by stricture, may induce acute cystitis. 
The continuation or frequent repetition of the same causes produces 
" chronic inflammation." 

Symptoms : Acute Cystitis. — Pain in the vesical region ; frequent 
desire to pass water, with burning in the urethra, and tenesmus, o r 
disposition to bear down or strain. There is fever, alternating wit h 
chills. The bladder may sometimes be felt as a small round swelling t 
sensitive upon pressure. In bad cases, there are nausea, anxiety 
delirium, and cold perspirations ; the scantily passed urine becomes 
purulent and bloody, alkaline and fetid. 

Chronic cystitis has usually much less severity of symptoms ; but it 
may be very distressing, from the tenderness and irritability of the 
bladder, and the frequent disposition to urinate, with dysuria. The 
urine is either mucous or muco-puruient. 

Treatment. — Acute cystitis, with perfect rest, may need leeching 
or cupping above the pubes or (leeching) at the perineum. As a lax- 
ative, castor oil is apt to be the best. Warm hip baths will be very 
soothing. Flaxseed tea maybe taken freely. Opium, hyoscyamus 
or belladonna may be called for by great pain or nervous irritability. 
O piuni or belladonna suppositories [F. 124, 125] , or laudanum eneinata, 



208 DISEASES OF KIDNEYS AND BLADDER. 

will answer best if anodynes have to be repeated often. In chronic 
cystitis, local depletion is much less likely to do good. The other 
measures named may be suitable from time to time ; also injections of 
lime-water and glycerin, or weak solution of nitrate of silver, or of 
sulphate of copper, or acetate of lead, in water or in glycerin, may be 
serviceable. Catheterism may at times be indispensable, both in acute 
and chronic cystitis ; but it should be avoided if possible, on account 
of the mechanical irritation of the instrument. 

RETENTION OF URINE. 

Synonyms. — Strangury, Dysuria, Ischuria. Although the mech an- 
ical or surgical causes and history of difficult or arrested urination do 
not belong to this work, it will be proper to speak briefly of its occa- 
sional importance, as a symptom in the course of diseases which every 
medical practitioner must meet. 

Retention of urine is either from mechanical obstruction, from 
spasm, with or without inflammatory congestion at the neck of the 
bladder, or from vesical atony or paralysis. The first occurs in cases 
of stricture, calculus, etc. ; the second under the influence of cantha- 
rides or turpentine, or in cystitis from any cause ; the third, in typhus, 
typhoid, and other low fevers and states of debility. 

It is very easy in all but the last named cases to distinguish reten- 
tion from suppression of urine. In low fevers, etc., when delirium 
exists, it is not at all difficult to make the diagnosis upon examination ; 
without it, this serious condition may be overlooked. A practitioner 
must never forget to ascertain whether his patient passes water or 
not. In all serious diseases, indeed, its regular inspection is important. 

In the semi-paralytic retention of low states, catheterism is generally 
required ; and, when distension and dulness upon percussion above the 
pubes, with absence of urinary discharge for twelve or twenty-four 
hours, or only dribbling, mark the case, the instrument may be used 
without delay, and repeatedly ; at least once daily if necessary. 

Spasmodic retention of urine, or strangury, with or without the 
concomitant existence of stricture or gravel, may demand other means 
of relief than the catheter. The warm hip bath, prolonged for half 
an hour, is one of the best measures. Cloths wrung out of hot water 
applied to the perineum and over the pubes may assist. Leeches to 
the perineum, when there is local tenderness, will often promote 
relaxation of the part. Laudanum enemata, and opium [F. 124, 125] 
or belladonna suppositories, will sometimes relieve when other measures 
fail. Anaesthetic inhalations might be resorted to in an extreme case. 
Hypodermic injection of morphia has been used. 

ENURESIS. 

Definition. — Incontinence of urine. Except from paralysis or some 
local lesion, this troublesome affection is not apt to occur in the adult. 
In children it is common, especially at night. 

Treatment. — Withholding fluids for some hours before bedtime, 
unless in very small quantities, and taking the child up to urinate after 
two or three hours of sleep, will generally prevent enuresis. Of medi- 



INFLAMMATION OP THE BRAIN. 209 

cioes, tnose most employed (with variable success)" are belladonna, 
benzoic acid [F. 126], and tincture of chloride of iron. 

Moral impressions, acting upon the child's sense of shame or wrong, 
are only proper to be made use of with great care and discretion ; but 
sometimes they have much power. 



AFFECTIONS OF THE BRAIN AND NERVOUS 
SYSTEM. 

INFLAMMATION OF THE BRAIN. 

Synonyms. — Encephalitis, Phrenitis, Meningitis, Gerebritis. The 
last two are not, of course, technically identical ; but they are not 
clinically separable. Inflammation of the membranes derives its im- 
portance from the implication of the brain. 

Varieties. — Simple and scrofulous encephalitis or meningo-cerebritis. 

Simple Meningo-cerebritis (meningitis). Symptoms.— Intense 
headache, redness of face and eyes, an excited look, dizziness, roaring 
in the ears, extreme sensitiveness to light and sound, restlessness, 
wakefulness, wild delirium. Vomiting is common ; the bowels are 
usually costive. Late in the attack in adults, at any period in chil- 
dren, convulsions may occur. Rigidity of the muscles is frequent in 
bad cases ; paralysis often follows convulsions. 

Stages. — These are generally described as three. 1st. That of active 
congestion and inflammation ; with hot, hard, rapid, full, regular pulse, 
morbid sensitiveness to light and sound, headache and delirium. 2d. 
That of commencing effusion and cerebral oppression ; with more 
moderate heat of the surface, stupor, and slow or irregular pulse. 
3d. That of cerebral disability or disorganization ; with unconscious- 
ness, convulsions, muscular rigidity or paralysis, and rapid, feeble pulse. 

Morbid Anatomy. — Except in traumatic cases, the dura mater 
rarely takes part m the lesions of encephalitis. Rather minute 
hyperaemic injection is found here and there in the arachnoid mem- 
brane ; sometimes opacity and thickening occur, with adhesions. In 
the pia mater, generally with considerable increase of redness, serum 
has been effused ; or even pus. The pia mater adheres firmly to the 
brain. The ventricles contain more serum than usual; sometimes 
several ounces. In some cases it is turbid, flocculent, or purulent. 
The brain itself is most frequently affected, with redness in the con- 
volutions, and dots of blood in the medullary portion; also, with 
softening in the gray or white substance, or in both. 

Diagnosis. — The distinctions between simple and tuberculous or 
scrofulous meningitis or encephalitis will be considered presently. 
Typhoid fever, delirium tremens, and acute mania maybe confounded 
with or mistaken for inflammation of the brain. 

Typhoid fever does not have vomiting, long-continued headache, 
or morbid sensibility to light among its symptoms; while tympanites, 
diarrhoea, bronchitic cough, etc., make it known. In delirium tremens, 
the origin of the affection in alcoholic excess, the usually horrible 
illusions, tremor and insomnia, without headache, are characteristic. 

18* 



210 DISEASES OF BRAIN AND NERVOUS SYSTEM. 

Acute mania is almost or quite without fever; often without headache; 
and the muscular strength is little impaired; vomiting, also, is absent. 

Subacute or chronic encephalitis, now and then met with, presents 
greater difficulty in distinguishing it from mania. Indeed, the best 
authorities in psychopathology (study of mental diseases) state that 
cerebral hyperemia and inflammation bear a not unimportant part in ' 
the pathology of insanity. (See Winslow on the Brain and Mind.) 

Children afford not unfrequent instances of another question in 
diagnosis ; — how far symptoms affecting the brain may or may not 
depend upon the stomach for their causation. " Gastric fever" and 
" infantile remittent" are phrases applied often to attacks occurring in 
childhood or infancy ; in which, with indigestion and vomiting, there is 
delirium, stupor, or apathy, with or without convulsions. In such 
cases, the heat of head and fulness of the carotid and temporal arteries 
are less, the gastric disorder, fur of tongue, etc., greater, than in cere- 
bral inflammation. Cholera infantum is often attended by brain symp- 
toms ; but its other features, the time of year, and locality (in a large 
city almost always) are distinctive. 

Prognosis. — Simple encephalitis, under good treatment, is not 
always fatal; but a majority of cases end in death. I remember sev- 
eral recoveries ; two from extremely severe symptoms ; — one in a man, 
the other a girl of ten years of age. In the latter, a convulsion pre- 
ceded convalescence. 

Causation. — Between fifteen and forty-five is the age most subject 
to this disease. Males are more liable than females to it. Hot 
climates predispose to it ; and so does intemperate living. Exciting 
causes are, blows or falls upon the head, exposure to the sun, violent 
or prolonged mental excitement, erysipelas of the head, scarlet fever, 
metastasis of rheumatic or gouty inflammation, repulsion of eruptions 
upon the skin, suppression of accustomed discharges. Extension of 
inflammation from the ear (otitis) to the brain is a possibility, import- 
ant not to be overlooked. 

Treatment. — No disease is more likely to be benefited by early 
venesection than acute inflammation of the brain. Bleeding should 
be the rule ; omission of it the exception, necessary in cases of debility, 
anaemia, etc. But its usefulness depends upon its being early ; and it 
should seldom be repeated. Leeching or cupping may follow it. In 
children, the difficulty of finding a convenient vein to open may cause 
dependence upon leeches or cups. 

Purging actively is very important ; by sulphate or citrate of mag- 
nesia, or, if dosing be difficult from delirium, croton oil [F. 127] or 
elaterium. After one free purging, moderate catharsis may be, if 
necessary, repeated every two or three days ; and the bowels should 
be kept open during the attack. 

Cutting the hair very short, or, still better, shaving the whole head, 
will aid in giving relief, and will allow the effectual application of cold. 
Pounded ice, in a bladder or bag of India-rubber, will do if watched 
and changed in place often, to prevent too great an impression upon 
one part. I prefer a linen cloth (as a cambric handkerchief) folded 
once, dipped in ice-water, and laid over the head; it should be wet 
freshly every few minutes, or the good effect is almost lost. Merely 
wetting the head now and then with cold water produces a reaction, 



INFLAMMATION OF THE BRAIN. 211 

not a sedation, which is required. If the feet be cold, they should be 
made warm by mustard foot-baths or sinapisms. In children, the 
prolonged warm bath may be useful. 

The diet in the first part of the attack should be as light and un- 
stimulating as possible. Oatmeal gruel, panada, rice, toast-water, 
may come first ; then milk, chicken-water, mutton broth ; later, beef-tea. 

Blisters are undoubtedly serviceable after the intensity of the in- 
flammatory excitement has begun to diminish. The best will be a 
blister over the whole scalp. 

In a late stage, with secondary debility, concentrated liquid diet, 
with alcoholic stimulants, and even opium at night, may be required 
to support the flagging energies of the system. 

Convalescence in the best cases may be slow. The faculties may 
remain feeble, and the brain morbidly excitable, for weeks or months; 
needing great care as to all mental impressions and efforts, lest a 
dangerous relapse occur, or chronic cerebral hyperemia, perhaps in- 
sanity, follow. 

Scrofulous Encephalitis (tubercular meningitis, acute hydroce- 
phalus). — From two to fifteen years is the age most apt to yield 
examples of this fatal disease. Premonitory symptoms usually occur; 
dulness, pettishness, and languor; headache; disposition to put the 
head in the mother's lap, or to lie down ; loss of appetite ; vomiting ; 
and costiveness. The child sleeps ill, with grinding of the teeth, or 
sudden starting with alarm. After four or five days, constant head- 
ache and anxiety of countenance, heat of head, sensitiveness to light, 
fever, and drowsiness, alternated with moaning or occasional scream- 
ing, and delirium at night, mark the case. 

Advanced symptoms are, total stupor, strabismus, convulsions, and 
paralysis. The pulse goes through similar changes to those of simple 
encephalitis: first febrile acceleration, then irregularity and slowness, 
lastly the rapidity of moribund prostration. The attack terminates 
on the average in between two and three weeks. 

Prognosis is always unfavorable in this disorder. I thought I had 
met with recovery in one case, the third of his family to be attacked ; 
he remained well, apparently, for a month ; and then died in convul- 
sions. 

Morbid Anatomy. — Since Papavoine, Rufz, and Gerhard showed 
the existence of a relation between tuberculosis and u acute hydro- 
cephalus," autopsic inquiry has proved fully, 1st, that tubercle-like 
granulations, with opacity and thickening t>f the arachnoid at the 
base of the brain, adhesion between the hemispheres, and serous effu- 
sion, characterize a number of the cases ; 2dly, that all of these lesions 
may be found without any tubercle whatever ; and, 3dly, that the 
amount of such deposit in most cases is not sufficient to modify greatly 
the course of the local disease, at least in such a manner as tubercle 
acts elsewhere. I conclude, hence (especially in view of such re- 
sults palpably shown in autopsies under my own eye), that the semi- 
transparent gray granulations found in the arachnoid after scrofulous 
meningitis may be rather tuberculoid inflammatory products than 
tubercles ; leaving the yellow deposits only to be regarded as of the 
latter nature strictly ; while it is rather the diathesis than the deposits 



212 DISEASES OF BRAIN AND NERVOUS SYSTEM. 

that make the disease to differ, as in progress and prognosis it clearly 
does, from simple meningitis or encephalitis. 

Treatment. — What can we venture to do in medication for a hope- 
less disease ? Not to abandon any case of it ; for, first, our diagnosis 
may not be infallible ; and, secondly, there is not, as in phthisis, 
obvious anatomical reason for anticipating a fatal result, in the nature 
of the case. Waiving argument, for which we have no space, my 
judgment is in favor of treating this form of inflammation of the 
brain on the same principle as simple meningitis, with more caution 
in depletion and other reducing remedies. I would not bleed from 
the arm ; but draw blood very moderately by cups or leeches ; purge 
freely, but not exhaustively ; blister the head or back of the neck ; 
apply cold with care, and allow liquid nourishment, such as milk and 
beef-tea, mutton or chicken broth, &c, from an early stage. If, in 
this mode, we do not save a patient whom autopsy afterwards shows 
to have been doomed to die of tuberculization in spite of any treat- 
ment, we shall still, according to the indications of clear analogy, 
have practised rationally ; the next best thing to being successful. 

HYDROCEPHALUS. 

Definition. — Water in the head; dropsy of the brain. This is 
almost always an affection of early life. Sometimes it is congenital. 
It is mostly a passive dropsical effusion ; certain cases show signs of 
a chronic or subacute inflammatory condition of the arachnoid mem- 
brane. 

Symptoms. — Languor, strabismus, convulsions, loss of appetite, 
increase in the size of the head. This last may be enormous ; the 
fontanelles expanding, and, in a slow case, the bones growing exces- 
sively large. The mental faculties nearly always grow dull. Bodily 
emaciation and debility attend. 

Although cases are known and recorded in which hydrocephalic 
persons lived for more than twenty years, the general rule is that they 
die in a few months ; either from cerebro-spinal disability or atrophy, 
or from some intercurrent disease not endurable by the impaired vital 
energies of the system. 

Treatment. — Small as is the encouragement given by experience in 
this affection, it is certainly justifiable to try measures not out of place 
in themselves. Such are, moderate purging, every few days, or once 
a week, sustaining the strength by nourishing food, and, if it be borne, 
cod-liver oil ; diuretics ; shaving the head and rubbing it nightly with 
mercurial ointment ; occasionally blistering the back of the neck ; in 
a child, preferably, by painting it with cantharidal collodion. 

Is pressure by bandages or adhesive straps, or puncture, tapping 
the head, to be advised? Were I to use either of these heroic 
measures, I would combine them. In a case clearly otherwise hope- 
less, a needle trocar and canula may be introduced through the coro- 
nal suture, an inch or a little from the anterior fontanelle ; then, during 
and after the withdrawal of a few ounces of fluid, a bandage may be 
used for pressure, watching its effects. 






INFLAiMMATION OF THE SPINAL MARROW. 213 



SOFTENING OF THE BRAIN. 

Pathologists generally recognize two forms of this ; 1. Acute red 
inflammatory softening ; and, 2. Slow, white, atrophic softening or 
degeneration of the brain-substance. Both receive the name of ramol- 
lissement. 

The former of these is farther definable as a local cerebritis ; whose 
symptoms are not nearly always separable, clinically, from those of 
meningitis or encephalitis, already described. Cadaveric inspection 
shows not only hypergemic redness and softening, but. sometimes, 
abscess, or even gangrene of the brain. This last (gangrene) is 
probably always the result of injuries. Induration of the brain may 
also follow (especially traumatic) inflammation of the brain. The 
cerebrum is more often affected with red softening than the cerebellum. 

Abscess of the brain is in a certain number of cases latent for a 
considerable time. Sudden headache is apt to be the earliest symptom. 
This is attended by feverishness, vomiting, difficulty of speech, numb- 
ness, convulsions, paralysis, and coma. Otitis and pyaemia are said 
to be, after injuries, the most frequent direct causes of it. 

Diagnosis of acute red softening. — The occurrence of imperfect 
coma, with rigidity of the muscles of the extremities, or of paralysis 
without loss of consciousness, will make probable this lesion. Most 
cases die within two weeks ; some within two or three days, 

White, atrophic softening or degeneration of the brain may take 
place as a result of old age, or from intense mental labor or excite- 
ment, from intemperance, or from embolism ; that is, obstruction of 
an artery within the brain by a fibrinous clot carried from some other 
.part. Its approach and progress are more slow and insidious than 
those of acute inflammatory ramollissement. Neuralgic pains in the 
limbs, followed by numbness and paralysis ; general debility, and dul- 
ness of the senses, gradually increasing to blindness, loss of hearing, 
etc., and a corresponding decline of the mental powers ; these are the 
usual symptoms, which may be extended over a period of many 
months. Death is sure to be the final result. 

Treatment. — If inflammatory red softening can be diagnosticated 
at an early period, a similar treatment to that named for acute 
meningo-encephalitis may be advised. Local depletion, at least, fol- 
lowed by counter-irritation by blisters, may be resorted to in a case 
which appears to be such ; the more freely, because apoplexy, which 
most nearly simulates it, presents very similar practical indications. 

Chronic atrophic white softening is not amenable to any such 
measures ; nor, indeed, to any active remedial treatment. Prevention, 
by avoidance of its causes, and palliation or economy of the waning 
powers of the system, are alone possible. The management necessary 
upon such indications must vary with every case. 

INFLAMMATION OF THE SPINAL MARROW. 

Clinical Synonyms. — Myelitis, Spinal Meningitis. The symptoms 
of this uncommon affection are, constant and severe pain in the back, 
increased by motion ; spasmodic contractions or rigidity of the muscles 



214 DISEASES OP BRAIN AND NERVOUS SYSTEM. 

followed by paralysis, fever, constipation of the bowels, and retention 
of urine. Authors state that in myelitis proper, as distinguished 
from spinal arachnitis, there is no pain nor muscular rigidity, but 
only paralysis of motion and sensation. 

Morbid Anatomy. — Diffuse redness and opacity of the arachnoid, 
swelling and infiltration of the pia mater, and effusion of serum, com- 
municating freely with the cavity of the cranium, are generally found. 
Adhesions of the membranes from plastic lymph are less common ; 
and still less so, though repeatedly recorded, is suppuration within 
the arachnoid. The dura mater is occasionally affected with inflam- 
mation, and even ulceration and gangrene, commencing from without. 
The cord may be reddened from injection of its substance, and 
softened ; more rarely, indurated in parts. 

Treatment. — Local bleeding, by rather free cupping or leeching 
along the spine, followed by a blister, and active purgation with saline 
cathartics, constitute the essential parts of the treatment of simple 
inflammation of the spinal cord or of its membranes. If the diagnosis 
be doubtful, the practice must be disproportionately less bold ; this is, 
of course, a principle of very general application in therapeutics. 

Epidemic cerebro-spinal meningitis will be considered hereafter, as 
cerebrospinal or spotted fever. 

SOTTENING OF THE SPINAL CORD. 

Rejecting the not uncommon view which refers ramollissement of 
the cord in all cases to inflammation, I have considered softening as 
one of the lesions produced by myelitis or spinal arachnitis ; but sepa- 
rate from this, as in the case of cerebral softening, the chronic 
atrophic degeneration which results in a similar change. 

The symptoms of spinal softening are, first, numbness in the ex- 
tremities, with a sense of coldness ; pain in a portion of the back, 
with local tenderness on pressure ; then impaired mobility, and gradual 
loss of sensation in the limbs, or in one limb if only one side of the 
cord be affected. When the anterior columns only are softened, motor 
paralysis prevails ; if the posterior columns, sensibility is impaired or 
destroyed. Difficulty in walking, especially on first rising in the 
morning, is an early symptom. Contractions and rigidity of muscles 
occur later. At a still more advanced period, loss of control over the 
bladder and rectum adds to the distress of the patient ; who is apt to 
suffer also from bed-sores, ulceration, and sloughing of the parts upon 
which the body rests ; the system becoming gradually exhausted. 

Prognosis and Treatment. — Recovery is not to be expected from 
atrophic spinal softening. The most unfavorable symptoms are de- 
cided paralysis, involuntary urination, and defecation, with alkalinity 
of the urine. Treatment must be palliative and supporting only. 
Passive exercise (as by riding in an easy carriage, sailing, or being 
carried) in the open air, will be beneficial ; and so may salt bathing, 
and frictions of the surface of the body. Good diet, appetizing tonics, 
and sometimes alcoholic stimulants very carefully regulated, may 
retard the decline of the patient. 



INFLAMMATION OF THE EYE. 215 



SPINAL IRRITATION. 

Under this term (now discarded by most writers upon nosology and 
diagnosis) have been included several affections of different pathology, 
and not always identical in symptoms. Pain and weakness in the 
back, without proof of any decided or progressive lesion of the cord, 
or either motor or sensory paralysis, appear to be the common features 
in such cases. I think a name should be reserved for this combina- 
tion, for practical or clinical use ; however, as in the case of dyspepsia, 
and some other complex disorders, the term may not define the disease. 

Some cases included in this account are really rheumatoid (chronic 
non-febrile rheumatism) affections of the sheaths of the spinal nerves; 
others are instances of myalgia ; that is, muscular pains, from weak- 
ness and exhaustion in the muscles. Others again display, with 
anaemia and general nervous debility, a real irritability of the cord, 
shown by (hysterical) spasms of some muscles, or general convulsion, 
under disturbing impressions of various kinds. 

Treatment. — The discovery of the nature of the case (as above 
indicated) is important. If, in an otherwise vigorous person, the 
attack come on after some exposure, the rheumatoid condition is most 
probable ; and then cupping along the spine will do the most good. 
Afterwards, counter-irritation, as by croton oil, may be used ; and 
wearing flannel next the skin will be important. 

Myalgic, or purely muscular pains, follow generally upon fatigue, 
and are best cured by repose; aided by warm frictions, as with spirit 
of turpentine, whisky and hot water, whisky and salt, &c. 

True spinal irritability (t. e. of the cord, not always attended by 
sensitiveness to pressure along the back) is nearly always an affection 
of the anaemic and weak. Iron and other tonics, with nourishing food, 
salt bathing, and pure air, are demanded; and, with these, mild counter- 
irritation over the spine. Hemlock or Burgundy pitch plasters ; re- 
peated dry cupping; painting with tincture of iodine ; and the use of 
croton oil externally, are the best measures of this kind for such a 
purpose. 

INFLAMMATION OF THE EYE. * x 

Although ophthalmology is appropriated as a department of surgery, 
every medical practitioner meets with cases of affections of the eye, 
so often as to make it proper to notice here, briefly, its principal acute 
disorders. 

Varieties. — Conjunctivitis (ophthalmia, by usage), simple, catar- 
rhal, pustular, and purulent (Egyptian, military, and gonorrhoea! 
ophthalmia, and ophthalmia neonatorum, i. e. of new-born infants); 
keratitis (corneitis) ; sclerotitis (rheumatic ophthalmia) ; iritis (simple, 
traumatic, syphilitic) ; retinitis. 

Simple and Catarrhal Ophthalmia : Symptoms.— Bloodshot ap- 
pearance of the eye, with soreness, pain, and dislike of light, charac- 
terize simple conjunctivitis. Blotched or irregular injection of the 
conjunctiva, becoming in severe cases general and velvet-like, with, 
sometimes, chemosis (raising of the mucous membrane in spots, like 
little water-blisters), and mucous discharge, agglutinating the lids to- 



216 DISEASES OF BRAIN AND NERVOUS SYSTEM. 

gether, especially at night; these are the symptoms of the catarrhal 
variety or grade. 

Treatment. — When the inflammation is severe and recent, leeches 
to the temple near the eye will do good. Iced sassafras-pith water 
may be applied by laying a light piece of linen, soaked anew every I 
few minutes, over the closed lids. Nitrate of silver solution, two* 
grains to the ounce of distilled water, is recommended to be dropped 
from a quill or camel's hair pencil into the eye twice daily. A saline 
cathartic at the beginning of the attack will generally be useful ; and 
so will be, a little later, a fly blister behind the ear. When conva- 
lescence has fairly commenced, the use of the injection may be made 
at longer intervals, once in a day or two ; the eye being then kept 
closed, if the mucous discharge be slight, by a strip of isinglass 
plaster over the middle of both lids. After recovery, the eyes will be 
weak for a time, and must be used with caution and moderation. 
Adhesion of the lids is best prevented, at any stage, by the application 
of spermaceti ointment, castor oil, or glycerin cream, to their margin. 

Persistent redness and swelling of the lids will often give way under 
the use, nightly, as an unguent, of the cerate of carbonate of lead 
[F. 88]. Painting the exterior of the lids, many times daily, by 
means of a camel's hair pencil, with diluted extract of lead (one drop 
of Goulard's extract in an ounce of water), followed by cold cream or 
glycerin cream at night, has, to my knowledge, relieved greatly cases 
of long standing "weakness" or irritability of the eyes. Granular 
conjunctiva, or " chronic ophthalmia," not yielding to the above 
measures, may be referred to the resources of the special ophthalmo- 
logist. Pustular ophthalmia is characterized by the formation upon 
the conjunctiva of small vascular elevations resembling pustules, 
although rarely discharging pus. In other respects, the attack re- 
sembles the catarrhal inflammation. 

Purulent Ophthalmia.— 1. Ophthalmia of infancy. Leucorrhoea 
or gonorrhoea of the mother may produce this ; or it may follow expo- 
sure to cold or damp air, acting upon a system predisposed by imperfect 
nutrition. The danger of it is, the possibility of rapidly destructive 
ulceration of the cornea, producing blindness. It is possible, how- 
ever, for a considerable ulcer of the cornea to heal, in a child, even 
without leaving an opaque cicatrix. 

Treatment. — Introduce, by inserting the smooth point of a small 
syringe just within the inner commissure of the lids, several times a 
day, a solution of three grains of alum to the ounce of water ; alter- 
nated occasionally with a solution, of one or two grains to the ounce, of 
nitrate of silver. As very much depends upon the vital energy of 
the child's system, especial care must be taken as to its nourishment, 
bathing, and the state of its bowels. 

2. Gonorrhceal Ophthalmia. — Produced by contact of the viru- 
lent poison of gonorrhoea, this is perhaps the worst form of inflam- 
mation of the eye. At the beginning, it (as well as ordinary purulent 
ophthalmia) may resemble catarrhal inflammation ; but its course is 
so rapid and violent as to become suppurative in one or two days. 
Haziness of the cornea, and chemosis, followed by ulceration, perfo- 
ration, or sloughing, may occur. Such ulcers are apt to leave white 
and opaque cicatrices, even if not very deep, in the adult. 






INFLAMMATION OF THE EYE. 217 

Treatment. — Begin with a brisk purgation. Then apply, at once, 
and frequently, in alternation, solution of alum, ten grains in an ounce, 
and solution of nitrate of silver, four grains in an ounce. If the 
specific character of the inflammation can thus be annulled, the 
destruction of the cornea may be averted. Sometimes good surgeons 
have applied the solid nitrate of silver to the ulcerated surface. The 
prognosis, however, in this form of disease, is generally unfavorable to 
the safety of vision. 

Keratitis. — (Corneitis). A zone of vessels in the sclerotic, imme- 
diately surrounding the cornea, with haziness in the latter itself, 
amounting in time to opacity, marks this affection. When developed, 
we will find a plexus of fine vessels, arranged in a crescent, or semi- 
circle, along the upper or lower edge of the cornea, or both. Intole- 
rance of light is great ; any exposure of the eye causes a flow of 
tears. Children and adolescents are most generally the subjects of 
inflammation of the cornea. It may be of short duration, the opacity 
disappearing, in a young person ; at a later period of life, it is more 
obstinate; and if the attack lingers for several months, cloudiness 
remains. 

Treatment. — Most subjects of corneal inflammation are of delicate 
frame and depressed health. Tonics and good diet are more likely, 
in them, to be indicated than depletion. Repeated blistering behind 
the ears will be proper. The bowels should be well opened, and the 
eyes sheltered from strong light, while photophobia (intolerance of 
light) exists. In no form of disease of the eye. however, unless for a 
short time in a very acute attack, should a patient be imprisoned in 
a dark room. The want of air, and even of sunshine, will do more 
harm than good. When otherwise in a state fit for it, he may go out, 
with the eyes protected by a shade or suitable glasses, or a veil. 
Good authority prohibits the use of nitrate of silver solutions, as mis- 
chievous in corneal inflammation. 

Sclerotitis; rheumatic ophthalmia. This is shown by diffused 
redness of the eyeball, with enlargement of the arteries converging to 
the margin of the cornea; and severe pain in the ball, with intolerance 
of light. 

Treatment. — Not satisfied that there is always proof of the 
"rheumatic diathesis" in every case of sclerotic inflammation, I 
should still incline to prescribe for it, as a general rule, a combina- 
tion of coichicum with an alkali (as carbonate of potassa), after a % 
saline cathartic. A blister may then be applied behind the ear or 
back of the neck. Anodynes are apt to be called for; as belladonna 
or opiates ; so severe is the pain in many instances. 

Iritis. — Some writers describe the forms of inflammation of the iris 
as simple, traumatic, gouty and rheumatic, scrofulous, and 
syphilitic. The first and last of these are the most important and 
distinctive. 

In either form of inflammation, a vascular zone in the sclerotic, near 
the cornea, fixedness and irregularity of the pupil, with a greenish 
hue of the iris if it be naturally blue, are the usual signs. 

Treatment. — In a robust patient, leeches around the eye ; in a 
weaker one, a blister behind the ear ; saline purgation, repose to the 
eye, and steaming it frequently over hot water, are measures that 
19 



218 DISEASES OF BRAIN AND NERVOUS SYSTEM, 

nearly all will agree upon. More difference of opinion exists as to 
the use of mercury in iritis. Some give it, to retard the effusion of 
lymph, in all cases. Others, only in the syphilitic. A number, rather 
increasing of late, in none. I would give calomel in all cases of active 
iritis, but in none so largely as to endanger salivation. One grain 
twice daily for a few days will be enough ; stopping it if the gums are 
at all affected. 

Maintaining moderate dilatation of the pupil is considered impor- 
tant in all cases of iritis. For this purpose, atropia is locally used. 
Once or twice daily there may be dropped into the eye two or three 
drops of a solution of two grains of sulphate of atropia in an ounce of 
water. 

Retinitis. — So obscure is the diagnosis of this, and so greatly has 
its pathology been modified since the introduction of the ophthalmo- 
scope, 1 that it will be best for us to refer for its consideration to works 
especially upon the Eye. (See Mackenzie, Laurence and Moon, etc.) 

OTITIS. 

Definition. — Inflammation of the ear. This is most common in 
children. Scrofulous inflammation and suppuration of the external 
meatus, with chronic discharge, is frequently met with. Scarlet fever 
not rarely is attended by otitis, extending from the throat ; sometimes 
ulceration destroys the membrana tympant, and even the ossicula / 
causing deafness. 

Otalgia, earache, occurs often without much inflammation, as an 
almost entirely neuralgic affection. Pain, however, is the first symptom 
of otitis ; with soreness on pressure upon the meatus or the mastoid 
process, and heat of the ear. An infant may suffer from this without 
being able to designate the seat of its distress. It cries or screams 
at intervals, and buries its head in the pillow, or leans the affected 
side against its mother's breast or arm. Often in the course of a day 
or two a purulent discharge gives relief to the intensity of the attack. 
In other cases pain returns again and again, the soreness continuing, 
without discharge, for weeks together. 

Extension of inflammation from the internal ear to the membranes 
of the brain is possible in severe acute otitis ; but it is almost as likely 
to happen in cases of long-continued otorrhoea, or discharge from the 
ear ; particularly if this be suddenly arrested. 

Treatment. — Earache may be relieved usually by dropping into 
the ear three or four drops of olive or almond oil, with one or two 
drops of laudanum. If continued pain, with heat and tenderness on 
pressure, show decided inflammation, a few American leeches may be 
applied behind the ear; and afterwards a small blister (when the leech- 
bites have healed) upon the same place. Painting with the cantharidal 
collodion will here prove very convenient. 

Chronic discharge from the ear should be treated with mild astring- 

1 The simplest ophthalmoscope is a perforated hand mirror, which reflects a 
strong light upon the eye, while the examiner looks through it. \nmicute in- 
flammations of the eye its use is unsuitable. Bouchut, however, has written a 
volume upon it as a means of diagnosis, even in diseases of the brain, as 
meningitis, etc. 



HEAT-STROKE. 219 

ents, very gently applied. Syringing is not nearly always necessary ; 
if done with force it irritates, and may cause headache and nausea. 
Pouring the lotion from a teaspoon, the patient lying upon the other 
side, and turning over to allow it to run out, will generally do better. 
Lotions so used should be warm. 

Castile soap and water ; lime-water; glycerin and rose-water (one 
part to five) ; and solution of acetate of lead, one or two grains in an 
ounce of water, will prove the best washes, and sufficiently strong to 
mitigate without too suddenly checking the discharge. 

Deafness (cophosis) may result from, 1. Accumulation of wax in 
the ear; 2. Inflammatory thickening of the membrana tympani ; 3. 
Obstruction of the Eustachian tube ; 4. Perforation of the tympanic 
membrane ; 5. Destruction of the ossicula of the ear ; 6. Paralysis of 
the auditory nerve. Only in case of the last is the patient unable to 
hear the ticking of a watch placed between the teeth. 

HEAT-STROKE. 

Synonyms. — Sunstroke; Coup de Soleil ; Insolatio. Two forms 
of heat-stroke undoubtedly occur. In one, the direct rays of the sun 
upon the head induce cerebral congestion ; in the other, excessive heat, 
often not under the immediate influence of the sun, affects the whole 
system with prostration, apparently from a blood-change ; the chemical 
operations of the economy being modified by heat in a manner incom- 
patible with the vitality of the blood. 

Symptoms. — Genuine sinistroke is commonly sudden. Falling 
unconscious, the head is very hot, the temporal arteries distended ; 
the breathing is apt to be stertorous (snoring), the pulse full and 
slow. In severe cases, convulsions may precede death. 

In heat-stroke of the second variety (more common than the first), 
almost equal suddenness marks the attack. There is. however, no 
excessive heat in the head ; the pulse is weak ; unconsciousness is less 
complete, and without stertor of the breathing ; the whole condition 
resembles syncope rather than apoplexy. 

Causation. — It is remarkable that few cases of heat-stroke occur 
in the country, among farm laborers : and very few at sea, even in the 
tropics. Large cities afford nearly all the cases. This looks as if the 
atmosphere had much to do with predisposing to it. at least by deteri- 
orating the blood, and lowering the resistance of the vital energy. 

It is nearly always, in the case of heat-exhaustion, those who have 
been fatigued by exertion, in the sun or shade, who are overcome. 
Drinking largely of cold water when thus exhausted, much increases 
the danger. Intemperate persons are particularly liable to heat-stroke. 

Treatment. — For sunstroke, or heat-apoplexy, cupping or leeching 
the back of the neck or behind the ears, should generally be the first 
remedy, after the application of ice or iced water freely to the head. 
The head and shoulders should be kept raised. A purgative enema 
should also be administered, and sinapisms applied to the lower limbs. 

Heat -exhaustion requires quite different treatment, in part at least. 
Cold should be applied to the head, and sinapisms to the spine, epi- 
gastrium, and limbs, in turn. Local depletion should be avoided. If 
syncopal symptoms be decided, ammonia may be for a few moments 



220 DISEASES OF BRAIN AND NERVOUS SYSTEM. 

applied to the nostrils; and, if the patient can swallow, aromatic 
spirits of ammonia may be given by the mouth, 10 drops every fifteen 
minutes at first, gradually increasing the interval. Mixed cases of 
course occur, demanding an intermediate or composite treatment. 

INSOMNIA. 

Definition. — 'Morbid wakefulness ; impossibility of sleep. 

Causation. — Apart from pain, or severe acute disease affecting the 
brain (as delirium tremens), insomnia may be brought on by intense 
or prolonged mental labor or emotional excitement. Excessive use 
of strong coffee or tea, or of belladonna, stramonium, or cannabis 
indica, may produce it. 

Pathology. — Only within a recent period has the correct view been 
adopted that, during sleep, the arterial circulation of the brain is at 
its minimum. In sleeplessness, the most certain error loci is, an ery- 
thism (morbid erectility) of the cerebral arteries, which keeps their 
circulation full and prevents sleep. It is not possible to be sure that 
this is all, as the nature of brain-action and nerve-force is unknown. 
But this furnishes a basis for rational management. 

Treatment. — This must vary with the cause. The overworked 
brain of the professional, literary, or business man must be withdrawn 
from his employment. Irregularity of the circulation dependent upon 
general debility must be met by tonics and generous diet. Accumu- 
lation in the head must be diminished by such physical exercise as 
the strength will bear. Decided cerebral exhaustion is apt to be 
attended by such loss of nerve force as will forbid much effort of any 
kind ; but milder cases of insomnia will be benefited by exercise. 
The brain should be especially allowed to rest from excitement near 
the usual hour for sleep. Hence a walk or the use of dumb-bells just 
before bedtime will be suitable. If the stomach be empty, a little 
easily digested food, even late at night, will promote sleep; notwith- 
standing the familiar fact that heavy suppers induce wakefulness or 
nightmare. A glass of lager beer at bedtime is, as my own experi- 
ence has proved, one of the best of hypnotics. 

The warm bath or pediluvium, with cold to the head, will be service- 
able in abstracting blood from the brain. Position of the body is 
important. The sufferer from insomnia may often be very sleepy 
before lying down — yet, once in bed, he becomes wide awake. Several 
persons, in such case, to my knowledge, have found it best to recline 
with the head and shoulders raised. Thus, by gravitation, the flow of 
blood to the head is retarded, and sleep is promoted. 

Of medicines, for simple insomnia, in the absence of pain, opium 
and other powerful narcotics are not appropriate. Hops, lactucarium, 
and hyoscyamus are strong enough. Bromide of potassium, in ten or 
twenty grain doses, is just now most relied upon as a cerebrovascular 
sedative. [F. 134.] 



NIGHT-TERRORS. 221 



NIGHT-TERRORS. / * 

Dr. C. West' gives the following description of an attack which I 
have seen a number of times, occurring in infants or children under 
ten years of age. " A child who has gone to bed apparently well, 
and who has slept soundly for a short time, awakes suddenly in great 
terror, and with a loud and piercing cry. The child will be found 
sitting up in its bed, crying out as if in an agony of fear, ' Oh, dear ! 
oh, dear! take it away! father! mother!' while terror is depicted on 
its countenance, and it does not recognize its parents, who, alarmed 
by its shrieks, have come into its room, but seems wholly occupied 
with the fearful impression that has aroused it from sleep. In from 
ten minutes to half an hour, as the terror abates, it may become quiet 
at once and fall asleep ; but frequently it bursts into a fit of passionate 
weeping, and sobs itself to rest in its mother's arms. In some 
instances a quantity of limpid urine is voided as the fit passes off, 
but this occurrence is by no means constant. Usually the remainder 
of the night is passed in tolerably sound sleep ; two attacks do not 
often occur in the same night." " Seizures of this kind may come on 
in a great variety of circumstances, and, according to the cause 
whence they have arisen, may continue to return for many weeks 
together, or may occur but a few times. As far as I have had the 
opportunity of judging, they are never the indications of primary 
mischief in the brain, but are always associated with some disturb- 
ance of the intestinal canal, and more or less obvious gastric disorder. 
In the majority of cases constipation of the bowels exists." 

My experience with such cases confirms that of Dr. West, as indi- 
cating that these attacks do not prove disease of the brain. But the 
nervous system of a child so affected must be morbidly susceptible ; 
and signs of indigestion, constipation, or irritation of the bowels are 
not always present. 

During the attack, the child should be at once gently lifted up from 
the bed, and either carried for a few moments or laid down in a dif- 
ferent position. Washing the face softly with a rag dipped in cool 
or cold water may arouse thoroughly. If any medicine be suitable, 
it will be a teaspoonful of camphor water. Care is needed to prevent 
the attacks. Violent exercise and mental excitement are almost as 
apt to bring them on as indigestion or constipation. The bowels 
should, however, be kept open, as by fluid extract of rhubarb, or 
senna, &c. To promote tranquil sleep, some one should remain with 
the child, if timid, for a while after it goes to bed ; or a light should 
be left burning low. A child liable to night-terrors ought to be 
allowed to finish its morning sleep undisturbed. Abundance of sleep 
is sedative to an over-excitable brain. Neglect of such precautions 
may convert a mere transitory functional disturbance into a serious 
attack of brain disease. 

1 Diseases of Children, p. 210. 
19* 



222 DISEASES OF BRAIN AND NERVOUS SYSTEM. 



APOPLEXY. 

Definition. — Sudden coma, produced neither by injury nor poison. 

Varieties. — Some terms once used have been shown to be without 

pathological justification ; as serous apoplexy, nervous apoplexy. 

Good authority still sustains, however, the mention of two forms at 

least of genuine apoplectic seizure : congestive and hemorrhagic. 

Symptoms. —Congestive Apoplexy . — Premonitory symptoms 
often seen are, flushed appearance of the face and eyes, heat of head, 
throbbing of the carotids, distension of the temporal arteries and jugu- 
lar veins ; constipation, languor, dulness, drowsiness; dimness of sight, 
vertigo, headache. The attack is marked by sudden stupor ; with 
slow and sometimes snoring respiration, full and slow pulse, dusky or 
turgid appearance of the face. The total loss of perception may be 
brief, its partial absence or deficiency continuing for some time. 
Slight convulsive movements are not uncommon. Paralysis of the 
muscles occurs only for a short time after the attack, if recovered 
from. 

Symptoms of Hemorrhagic Apoplexy.— Generally no clear pre- 
monition is given, the attack being very sudden ; a stroke, literally. 
Unconsciousness is complete, for some seconds, minutes, or hours. 
After this, general or local paralysis, most often hemiplegia, is left ; 
the mental powers also, in many cases, being impaired, at least tem- 
porarily. During the coma, the breathing is commonly stertorous, and 
the pulse slow, and somewhat full, the head hot, the face more or less 
dark or flushed. But the fulness of the bloodvessels and heat of the 
head are much less, as a rule, than in congestive apoplexy. 

Anatomy and Pathology. — In the congestive form, excessive cere- 
bral hyperemia produces coma by pressure upon the brain ; the ex- 
tremest degree of which (vascular pressure) is met with in strangula- 
tion. 

In hemorrhagic apoplexy, from the rupture of a degenerated artery, 
either in the substance of the cerebrum or cerebellum, in the ventri- 
cles, or under the arachnoid membrane, effusion of blood occurs, and 
a clot is formed. If this be small, it may be gradually absorbed ; 
autopsic inspection sometimes shows the remains of such, where an- 
other hemorrhage has caused death. 

Fatty degeneration of the arteries of the brain has been repeatedly, 
but not always, observed. The parts of the brain most liable to ex- 
travasation of blood are (Aitken) stated in this order: 1. corpus 
striatum, thalamus, and hemispheres above them; 2. corpus striatum 
alone ; 3. hemisphere above the centrum ovale ; 4. thalamus alone ; 
5. lateral lobes of cerebellum; 6. mesocephalon; 7. posterior lobe of 
cerebrum ; 8. before the corpus striatum ; 9. pons Varolii ; 10. middle 
lobe of cerebellum ; 11. meninges ; 12. peduncles and olivary body. 
The age of the clot may be ascertained in part by the discovery, with 
the microscope, of blood-crystals ; which are not found until after 
seventeen or eighteen days from effusion. 

Diagnosis. — Apoplexy is to be distinguished from uraemia, alco- 
holic intoxication (dead drunkenness), narcotic poisoning (as from 
opium), compression of the brain, or concussion, from blows or falls, 
asphyxia (suffocation), sunstroke, catalepsy, cerebral hysteria, acute 



APOPLEXY. 223 

softening of the train, and spotted fever or " cerebro-spinal meningi- 
tis ;" as well as from all forms of syncope. From uraemic coma it is 
only to be known by the history of the case, showing a renal origin 
for the symptoms, in partial or total suppression of urine. Alcoholic 
intoxication is revealed by the odor of the breath, and the attendant 
circumstances. Similar aid exists sometimes in cases of narcotic 
poisoning ; in opiate narcotism, moreover, the pupil is contracted ; in 
that from most other narcotics, it is as firmly dilated. Concussion 
and compression of the brain are generally suggested by the position 
of the body (if found without a history), and the external marks of 
injury. Asphyxia is also usually pointed out by the condition of 
things surrounding the patient. 

In asphyxia, blueness of the lips, and embarrassment of respiration, 
with coldness of the surface, show the origin to be in the function of 
breathing. Sunstroke is attended by feebleness of the pulse, at least in 
the majority of cases ; in some, it is, identically, a congestive apoplexy. 
In catalepsy, there is rigidity of the muscles, with rapidity of the 
pulse, susceptibility of the pupil to light, brief duration and repeated 
recurrence of the attack, without any paralysis. Cerebral hysteria is 
rare, and occurs only in females, whose previous disorders of the ner- 
vous system will aid in interpreting even coma as belonging to the same 
category. Acute red softening of the brain may be very difficult to 
distinguish from apoplexy. It is, however, seldom if ever so sudden 
in its invasion ; there is more slobbering or flow of saliva, and water- 
ing of the eyes; and there is not the partial or entire restoration of 
the faculties which an attack of apoplexy, not fatal, allows so often. 
Spotted fever, or " cerebro-spinal meningitis," will be especially de- 
scribed, and its diagnosis considered, in another place. 

Syncope, of any form or origin, is always marked by pallor, cold- 
ness, and loss ofpidse. 

Prognosis. — This is always alarming ; most so as there is the most 
reason to believe that cerebral hemorrhage has occurred ; and, there- 
fore, especially in those advanced in life. In younger subjects, where 
stertor of breathing is absent, under proper treatment, congestive 
apoplexy may be entirely recovered from. So may a single attack of 
the hemorrhagic form, with a small clot only, and limited, transient 
paralysis. Each succeeding attack becomes more dangerous ; a third 
is seldom survived. The immediate danger connected with an attack 
of apoplexy should not be considered over for ten days at least after 
the stroke itself. Very seldom, indeed, after a hemorrhagic attack, 
are the mental or bodily powers so good, for the rest of life, as before. 

Causation. — Age is the most constant promotive cause of apoplexy. 
Cases are on record, though of extreme rarity, in children ; between 
thirty and fifty it is much more frequent ; but after fifty it is one of 
the most common modes of death. Arterial degeneration is here the 
general occasion of the catastrophe ; some mental excitement, or bodily 
shock or effort, as danger, or joy, or a few glasses of wine, or the 
stooping posture, or straining at stool, causing a rupture of the weak 
vessel, and fatal cerebral hemorrhage. Neither sex seems to be more 
liable to this disease than the other. 

Full living, especially with alcoholic intemperance (even moderate) 
and indolent habits, predispose to it in a marked degree. So does 



224 DISEASES OF BRAIN AND NERVOUS SYSTEM. 

excessive brain-work. Florid, short-necked, big-bellied people are 
most exposed to it. Hypertrophy of the left ventricle of the heart is 
believed also to promote it. After dinner and during sleep are the 
two most likely times for the attack to occur. 

Treatment. — The younger the patient, and the more vigorous his 
antecedent health, the more probable is the existence of the congestive 
form ; and, also, the better the prospect of recovery from hemorrhage 
within the cranium, if, only, the effects of pressure be averted at the 
time. If, then, in a person under fifty, not before of broken constitu- 
tion, we find the head hot, face turgid and flushed, the arteries and 
veins of the neck and temples full, the pulse also strong, and the 
heart's impulse so (or the heart's action vigorous though the pulse 
at the wrist be oppressed), bleed. Watch the effect, with the hand 
on the pulse. If the breathing improve, and the pulse rather gain 
than lose in naturalness and force, take out ten or twelve ounces. 
Should the improvement progress, but still a relapse into deeper 
stupor afterwards threaten, either the lancet again, or cupping to the 
nucha, may be used. 

Older or more doubtful cases may be treated tentatively, with cups 
alone, aided by mustard plasters to the legs, back, and epigastrium 
in turn ; with laxative injections into the rectum during the attack, 
and saline purgatives afterwards. The head should be kept raised, 
and cooled with wet cloths until its temperature become normal. If 
the hair be thick, it should be cut very short or shaved off entirely. 

When, however, there is reason, as usually is the case in really old 
or broken down patients, to believe that structural degeneration, 
arterial or that of ramollissement, is the source of the attack, loss of 
blood will be out of place. It may even, by exhausting the enfeebled 
system, hasten death. Such cases, if they survive the first apoplectic 
fit, require rather nourishing diet, and sometimes even tonics, to 
support strength, favor repair, and prolong life. Great delicacy of 
judgment, of course, is necessary in deciding, in different cases, 
between these apparently so opposite modes of treatment. It is right 
to add, that the tendency of medical opinion, for the last ten or 
twenty years, has been towards the curtailment, to a great extent, of 
the use of the lancet in apoplexy. 

Where a moderately plethoric condition is present, and the taking 
of blood, generally or locally, is not decided upon, purgation is safe 
and likely to be useful. Jalap, resina podophylli, or croton oil, in small 
doses, will have the advantage of convenient administration [F. 
135, 136]. 



PARALYSIS. 



Varieties. — According to the proximate cause : 1. Cerebral palsy ; 
2. Spinal ; 3. Keflex paralysis ; 4. Toxaemic (e. g., lead palsy); 5. Hys- 
terical palsy. According to the extent of the affection: Facial or 
other local palsy ; Hemiplegia; Paraplegia; General paralysis. Ac- 
cording to its nature: Motor (acinesia), and Sensory paralysis (anaes- 
thesia). 

Facial Palsy. — This is an affection of the portio dura of the 
seventh pair of cephalic nerves, the motor nerve of the face. It occurs 



11 

: 



PARALYSIS. 225 

at any age, usually from rheumatoid inflammation of the sheath of the 
nerve at its escape from the cranium through the stylo-mastoid fora- 
men. One side of the face is without change of expression ; and the 
eye on that side is not closed (in severe cases) from the paralysis 
affecting the orbicularis palpebral muscle. The tongue is not affected 
in its movements. 

The facial motor nerve is not often involved in the much more serious 
cases of cerebral palsy. Absence of disturbance or of incompleteness 
of control over the tongue, while the power over the eyelid is partly or 
wholly lost, with the absence also of severe cerebral symptoms, will, 
especially in a young person, make the diagnosis easy as well as im- 
portant. The prognosis is, generally, of recovery in a few days or 
weeks. The treatment of this form of local palsy may be by repeated 
small blisters behind the ear ; followed, when convalescence has begun, 
by some warm covering (cotton wadding, flannel, or silk) to protect 
the part from cold. 

Other local Palsies. — Pressure upon a nerve may cause its paraly- 
sis, generally temporary. I remember the case of a man whose hand 
was rendered powerless for about three weeks by sleeping all night 
with his arm bent under his head. Frictions, the endermic application 
of strychnia, and galvanism were used in that case. Writer's cramp, 
or scrivener's palsy, is the result of exhaustion of certain muscles from 
over use. Its cure is rest. 

Palsy of the optic nerve is designated as amaurosis ; of the sense 
of hearing, cophosis ; of taste, ageusti a ; of smell, anosmia. Except 
the first, however, these terms are not much used. 

Hemiplegia. — Brain-lesion is most often the cause of this affection ; 
either an apoplectic clot, a tumor, or softening. Spinal disease may, 
however, produce it; and some cases are, by writers upon the subject, 
referred to a peripheral or reflex origin. There may occur, also, tran- 
siently, epileptic, choreic, and hysterical hemiplegia. Owing to the 
decussation of the anterior pyramids of the medulla oblongata, lesion 
of one side of the brain produces paralysis of the other side. In spinal 
lesion the palsy is usually on the same side. Brown-Sequard, how- 
ever, has shown decussation in the upper part of the cord also. 

Symptoms. — Suddenly, almost always, but not always with loss of 
consciousness, the patient loses the power of motion, and more or less 
of sensation, on one side. In complete cases, the parts involved are 
the arm and leg, the muscles of mastication (with the buccinator), and 
the half of the tongue. In trying to protrude the tongue it is pushed 
out towards the affected side ; in retracting it, the reverse happens ; 
that is, it is drawn towards the sound side. The palsied cheek hangs ; 
but the eye can be shut or opened at will. The third, fifth, and ninth 
nerves are especially apt to show implication by disturbance of the 
actions under their control; of the fifth, those of the muscles already 
mentioned, as well as of facial and lingual sensation ; of the third, loss 
of power to lift the eyelid, strabismus, and dilatation of the pupil ; the 
ninth, one-sided movement of the tongue, affecting also the speech. 

Hemiplegia may be attended either by rigidity or relaxation of the 
muscles ; and the former may be early or late. Where there is decided 
relaxation in cerebral paralysis, it is probable that white softening, or 
atrophy from embolism of the brain is the lesion, with or without a 



226 DISEASES OP BRAIN AND NERVOUS SYSTEM. 

clot ; where early rigidity is marked, an apoplectic clot may be inferred. 
Late rigidity is probably due to an atrophic state of the muscles ; a 
" rigor mortis in vitce." 1 Contradictory accounts are given by authori- 
ties as to the susceptibility to galvanic excitation of th^ muscles on 
the sound and on the paralyzed side. It is probable that the loss 
of excitability of the muscles is in proportion to their atrophy. 

The Prognosis in hemiplegia depends greatly on the ascertain- 
ment of its causation. If it follows an epileptic fit, or attack of 
chorea, or occurs in a hysterical subject, it may be of comparatively 
brief duration, ending in recovery. If an apoplectic attack precede 
it, or if any lesion of the brain be inferred from the history of the case, 
the prospect is bad. Partial improvement may occur, not often entire 
restoration ; and renewed attacks or " strokes" are likely to follow. 

Treatment. — Essentially the same principles are applicable to this 
as have been mentioned in connection with apoplexy. The younger 
the patient, the more vigorous his or her previous health, and the 
fuller the circulation, the more appropriate will be the general or 
local abstraction of blood, to diminish pressure upon the brain. 
AVhere softening is apprehended, bleeding should be exceptional and 
cautious. Epileptic, choreic, and hysterical hemiplegia indicate little 
or no depletion as a rule. Rest, regulation of the bowels, and coun- 
ter-irritation by dry cups to the upper part of the spine, and after- 
wards a blister; with frictions, as with brandy and red pepper, or 
whisky and hot water, or salt and spirits, to the affected limbs ; these 
are measures of general utility. A seton in the back of the neck is 
sometimes recommended. As to strychnia, it is not safe where 
cerebral or spinal irritation is likely to exist, as near the commence- 
ment of most attacks. Even at a late stage, it should be used with 
extreme caution, watching its effects [F. 137] . Precisely the same 
statement may, upon the best authority, be made as to electricity, in 
cerebral paralysis. In the hysterical form, if it last long, electricity 
may be applied locally, with safety and advantage. In any curable 
case, passive exercise of the weak limbs will be very useful. 

Paraplegia. — This is paralysis of both the lower extremities. 
Spinal disease or injury is its source ; with or without cerebral im- 
plication or complication. It may come suddenly or gradually ; 
generally its beginning, at least, is sudden. Reflex paralysis as de- 
scribed by several authors, is sometimes paraplegic. 

Symptoms. — In organic or spinal paraplegia, as well as in the reflex 
form, numbness in the feet and pain in the back are apt to be early 
signs. The power of motion is lessened or lost in the lower limbs. 
The muscles may be either relaxed or contracted. The lesion of the 
spinal marrow, if progressive, is productive finally, in many cases, of 
loss of power over the bladder and sphincter ani. Bed-sores, with 
deep ulceration and sloughing, may occur in protracted cases. 

Treatment. — When myelitis is believed to exist, at an early stage, 
local depletion to a moderate extent, in otherwise good subjects, may 

1 I have above, purposely, avoided alluding to the complications introduced 
of late into the special pathology of paralysis, by the vivisections of JBrown- 
Sequard and others ; because, brilliant as they are, while they have unsettled 
much, they do not appear to me to have positively settled anything. 



PARALYSIS. 227 

be advised. In any case, counter-irritation (not vesication, in a bed- 
ridden patent, unless he can lie well on either side), by repeated sin- 
apisms, or stimulating liniments [F. 138, 139], will be proper. 

While inflammation or active irritation of the spinal cord is made 
apparent by the symptoms (pain, cramps, muscular twitchings. or 
rigidity) strychnia is not suitable. After these have subsided, it may 
be given, — not more at first than the thirtieth of a grain twice daily. 
If it produce jerking movements of the hands or feet, or nervous rest- 
lessness, or any marked uneasiness, it should be suspended. Elec- 
tricity may be used, with similar caution, in a secondary or relatively 
late stage of paraplegia. Moderate (at first very gentle) shocks of the 
interrupted circuit are preferred. 

Hysterical Paralysis. — In females, this is among the many forms 
of functional disorder which that strange and not yet clearly defined 
disorder, hysteria, may produce. It is diagnosticated by the aid of the 
history of the patient. Dr. Todd stated that, in it, the affected limb 
(it is most often hemiplegic) in walking is dragged after the other, as 
if a dead weight ; while in cerebral hemiplegia the palsied leg and foot 
are brought round in a curve, the body being bent toward the souud 
side at the time. I am doubtful of the universality of this sign. 

Treatment. — Tonics, good nourishment, and change of air (in a 
word, analeptic management), are most needed in nearly all hysterical 
cases. For the paralysis itself, electricity has been found useful. 
Mild shocks for a few minutes twice a day may be given with the 
magneto-electric apparatus. 

Reflex Paralysis. — From the times of Whytt and Morgagni. occa- 
sional instances of palsy, of motion or sensation, caused by an injury 
at a distance from the affected parts, have been recorded. Since 
Stanley's paper (1833) asserting the production of paralysis, some- 
times, by disease of the kidney, a number of medical writers have 
added to the list of supposed cases of " paralysis without apparent 
lesion." Worms, dysentery, diarrhoea, uterine irritation, teething 
and external injuries are all thought to induce reflex paralysis in cer- 
tain instances. Diphtheritic and scarlatinal palsies have by some been 
placed in the same category. The simplest and clearest cases are 
those of wounds ; e. g., Morgagni's case, in which amaurosis was 
suddenly produced by a blow upon the eyebrow, affecting the supra- 
orbital nerve. I would exclude most of the asserted instances of 
visceral reflex paralysis. 

The 'pathology of this form of palsy is a subject of much controversy. 
To my judgment (after reading considerably upon it) the best expla- 
nation is that of Handfield Jones and S. W. Mitchell ; expressed in 
the term proposed by the former, — " inhibitory action." Denying, 
against no matter what present authority, the existence of inhibition 
or repression as ever proved to be a normal function of any nerve 
(such as some assert on the ground of experiment in regard to the 
pneumogastric), I consider it most reasonable to admit it here 'patho- 
logically. In other words, a morbid impression, from injury or dis- 
ease, in one part of the body, being transmitted along a nerve to a 
nerve-centre, overwhelms or paralyzes it; this effect being shown, of 
course, in the parts to which it distributes nervous branches. 

Treatment. — In true reflex paralysis, of short or moderate dura- 



228 DISEASES OF BRAIN AND NERVOUS SYSTEM. 

lion, the removal of the irritant cause produces instant relief; as in 
II. Jones' case, where strabismus from palsy of the external rectus 
oculi muscle disappeared after a piece of dead bone was extracted from 
a whitlow on the thumb ; or Lawrence's in which blindness of one eye 
(of thirteen months' standing) was cured by the extraction of a carious 
tooth, with a splinter of wood projecting from one of its fangs. When 
the nature of the case does not admit of such prompt relief, if the 
diagnosis be clear, the same indication remains ; to address our reme- 
dial measures to the seat or source of peripheral irritation. Palliate, 
if we cannot cure, the trouble there, and we will obtain palliation, if 
not relief, of the reflex disability. Electricity has proved signally 
useful in the subsequent treatment. This form of disorder is, how- 
ever, very rare. 

Diphtheritic Paralysis. — After the termination of an attack of 
diphtheria, commonly within three weeks, the muscles used in swallow- 
ing and speaking, less often those of the upper and lower limbs, and 
the sense of sight, may be partially paralyzed. Loss of sensibility 
usually accompanies the loss of motor power. This condition of things 
may last for weeks or even months, but is generally recovered from. 
Whether the immediate cause of the paralysis is the peripheral lesion 
of the nervous terminations (in the pharyngeal and laryngeal affection) 
or the toxemic influence, upon the nerve-centres, of the morbid poison 
of diphtheria, cannot yet be decided. In extended palsy as a sequela, 
I believe the latter to be the more probable explanation. 

Treatment. — Passive exercise, stimulating frictions, and electricity, 
sometimes with change of air, and sea-bathing, are suitable measures 
for this affection. 

Syphilitic Paralysis. — The most unequivocal instances of this na- 
ture are accounted for by periostitis within the cranium, involving the 
dura mater, or, by nodular exostosis, pressing upon the brain. The most 
remarkable fact connected with such cases is the recorded experience 
showing the prompt curative effect upon it of iodide of 'potassium 
[F. 140]. Obscure paralysis, without apoplectic symptoms, and in a 
syphilitic constitution, may be tentatively so treated, on the basis of 
such experience. 

Lead Palsy. — Considerable time of exposure to the influence of lead 
is generally necessary to cause this. So commonly does it first affect 
the extensor muscles of the forearm, that the cognomen of " wrist-drop" 
is often applied to it. When it lasts for some weeks, the muscles waste 
away. A blue line is observed to form along the edge of the gums. 
Pain precedes the palsy, and attends recovery of power. During the 
attack, the muscles have their excitability by electricity considerably 
diminished or lost. 

Mostly, though after a long time, lead palsy is recovered from. 
Iodide of potassium appears to act as an eliminant of the lead accu- 
mulated in the system. Ergot is asserted by some to be curative also. 
Paradaic electricity has been found decidedly beneficial ; used in mode- 
rate strength for a few minutes two or three times a day. (See Medi- 
cal Electricity, in Part I. Sect. III.) 

Mercurial palsy is occasionally met with in those who work in the 
metal. Mostly tremor is a predominant symptom. Early withdrawal 



INFANTILE PARALYSIS. 229 

from the influence of the cause, and the continued use of the iodide of 
potassium, are the principal measures of treatment. 

Paralysis agitans or shaking palsy is described as a more or less 
constant involuntary and uncontrollable shaking, of the hands, arms, 
head, or, progressively, of the whole body. Slight or moderate degrees 
of such tremor are common enough, from general nervous debility. 
Extreme cases evince the wreck of the cerebro-spinal system, and are 
therefore incurable. No especial treatment can be pointed out for 
this affection. 

Wasting Palsy. — (Cruveilhier's). A few of the muscles of one 
limb, or the voluntary muscles of the whole body, may lose their 
power, and then waste away almost to nothing. The shoulder and 
the ball of the thumb are frequent points of commencement for the 
palsy and atrophy. Insidious in its approach, the affection may last 
from six months to several years. It may end in recovery, in perma- 
nent arrest at a certain stage of the disease, or in death. Twelve 
months is the earliest recorded period for the occurrence of a fatal 
end. This end is the result always when the trunk is invaded. After 
death, the spinal marrow has been examined in but a few cases. No 
lesion has been found in most of them ; in a certain number it has. 
But our methods of inspection of nervous tissue are yet too imperfect 
for it to be pronounced that such an atrophic disease is independent 
of the nervous centres. It may be the ganglia which regulate nutri- 
tion that are in fault. 

Duchenne's Disease— * 'Ataxie locomotrice progressive." Rheu- 
matoid pains, in this affection, precede loss of power. Occasional 
strabismus and incontinence of urine may occur. Then there is an 
awkward, unsteady gait ; the sensibility of the feet becomes blunted, 
and walking is insecure. If the patient shuts his eyes he falls down ; 
and even with them open he reels as if drunk. Co-ordinative power 
over movements is lost. The duration of this progressive disease 
varies from six months to ten or twenty years. It is most common 
in males of middle age. That this is a spinal affection is obvious, 
even without many autopsies to prove it so. Lesion of the posterior 
columns of the cord has been several times found. In its treatment — 
hygienic management, general tonics, electricity, and very careful use 
of strychnia, may be tried, without much hope. 

General Paralysis of the Insane.— Only a minority of insane 
persons have this affection ; which comes on at an advanced stage of 
chronic mania, melancholia, or dementia. Difficulty of speech, and 
general tremor, characterize it, followed by the gradual loss of all 
muscular and sensory power. It is incurable. 

INFANTILE PARALYSIS. 

Under this name (perhaps not very well chosen), Dr. C. F. Taylor 
designates what Handfield Jones would call paresis of the nervous 
centres, so far as, in infancy, to arrest nutrition as well as abridge 
power in the limbs. Dissipation or bad health in the parents will 
predispose to this in children. No violent symptoms attend the 
attack. Mostly, with care, it tends to recovery. But want of know- 
ledge or attention may allow deformity to result from it ; especially 
20 



230 DISEASES OF BRAIN AND NERVOUS SYSTEM. 

club-foot. " Talipes equinus" (in which the heel will not touch the 
ground), says Dr. Taylor, 1 " is the first, and simplest, and most natu- 
ral sequence of the paralysis — the weight of the foot being all that 
is necessary to produce it — and no other form of talipes is likely to 
occur while the patient lies in bed. The bending of the ankle out- 
ward (talipes varus) is the result of weight on a foot with a shortened 
tendo-Achillis ; bending inward (talipes valgus) of the ankle is the 
result of weight partially overcoming the gastrocnemius, soleus, &c. ; 
and talipes calcaneus (where the toes are raised so as to be unable to 
touch the ground at the same time with the heel) of weight entirely 
overcoming those muscles." The author just quoted concludes from 
special experience that all such deformities are preventable by proper 
care as to the position and use of the limbs and muscles of all parts 
of the body during the paralytic or paretic state. The treatment of 
club-foot is a subject for surgical treatises. 2 

In some cases, fatty degeneration of the muscles takes place to such 
an extent as to render the case almost or quite incurable. Brodie 
observed that a case is likely to recover, in which, when the child is 
lying on the back, there is power to draw the limbs up by flexing the 
thigh towards the body. 

Treatment of infantile paralysis should consist of general recupe- 
rative management, including tonics (strychnia in some cases, with 
care) and cod-liver oil, salt bathing, passive exercise of the affected 
limbs, and galvanism. The latter must be cautiously conducted in 
children. Local application of heat is advised by Drs. Taylor and 
Hammond. The former prefers dry heat ; seating the child before a 
fire and thrusting its legs through a screen, so as to be thoroughly 
warmed for hours together. Dr. Hammond immerses the paralyzed 
limb in hot water, at 140°— 160°. 

EPILEPSY. 

Definition. — Periodical convulsions, with unconsciousness during 
the attacks. 

Varieties. Grand mal and petit mal of the French ; the latter is 
the eclampsia minor of some writers ; in which unconsciousness occurs 
with scarcely any convulsion. 

Symptoms. — Premonition occurs in a minority of cases before an 
attack ; headache, dizziness, terror, spectral illusions, or the epileptic 
aura. This is a creeping or blowing sensation, like that of a current 
of air or stream of water, beginning in a hand or foot, and extending 
toward the trunk. It (if it occur) immediately precedes the paroxysm. 
Then, often with a scream, the patient falls down, and is violently 
convulsed. Foaming at the mouth, grinding of the teeth, and biting 
of the tongue, are common ; the face is flushed, the eyeballs roll, the 
pupils are unaffected by light, sometimes vomiting, or involuntary 
urination or defecation takes place ; and respiration may be very 
laborious. 

1 Infantile Paralysis, p. 83. 

3 Adhesive plaster has lately been successfully used for gradually rectifying 
congenital club-foot, in early infancy. 



EPILEPSY. 231 

The fit lasts on an average from five to ten minutes. The interval 
between the attacks may be from several months down to a few hoars. 
Old cases (as in lunatic asylums) may have two or three paroxysms 
daily. They vary much even in the same individual. 

The condition after the attack is also various. Generally, drowsi- 
ness or deep sleep follows it ; or headache, debility, or delirum ; some- 
times maniacal frenzy. Homicide has been committed in this state ; 
for which, of course, the person is not criminally responsible. 

Anatomy and Pathology. — Epilepsy is not often the immediate 
cause of death. Autopsies of epileptics (Schroeder van der Kolk) 
have shown changes especially in the medulla oblongata ; dilatation 
of the bloodvessels being prominent. Exaggeration of reflex motor 
excitability, with loss of the controlling power of the brain over the 
spinal axis, would seem to be parts, at least, of the morbid condition. 
Marshall Hall's idea of "trachelismus," or temporary partial asphyxia 
from spasm of the muscles of the neck, has been exploded. Brown- 
Sequard's notion of the importance of the aura, as indicating a peri- 
pheral irritation at its seat, has, after causing the tentative amputation 
of a few limbs, suffered the same fate. 

Diagnosis. — From hysterical convulsions, which also may be peri- 
odical and violent, those of epilepsy are distinguished by the total loss 
of consciousness, — which is partially retained during the hysterical 
paroxysm. Curability belongs also much more to the latter than to 
the epileptic disease. 

Prognosis, — Few cases of genuine epilepsy recover. The younger 
the patient, and the longer the interval, the more hope. Life may 
last indefinitely with the disease. Gradually, in most cases, the men- 
tal faculties are impaired. Yet several great men have been epileptic ; 
Caesar, Mahomet, Petrarch, Napoleon, Byron. 

Causes. — Hereditary transmission of this disease is common. In- 
temperance, venereal excess and self-abuse, blows on the head, and 
fright, are among the most frequent exciting causes. 

Treatment. — During the paroxysm, when habitual, little or nothing 
is to be done. Place the patient so that he cannot strike his head or 
limbs against anything hard ; loosen the clothing about the neck to 
favor free respiration and circulation ; and insure fresh air about the 
patient; that is all. An occasional convulsion requires treatment; 
of that more will be said hereafter. (See Convulsions.) 

To break up the recurrence of the fits is the problem, for which a 
vast number of remedies has been tried, in vain. To name them would 
be to go over almost half the materia medica. Prominent, since 
nitrate of silver was abandoned as useless, in this disease, have been 
belladonna, arsenic, valerianate of zinc, digitalis, and bromide of potas- 
sium. I have known valerianate of zinc to postpone the paroxysm 
for considerable periods. Beginning with one grain twice daily, it 
may be gradually increased to three or four times that amount. A 
case of recovery occurred under my knowledge in which rather large 
doses of digitalis were persevered in for several months. Bromide of 
potassium 1 is now the favorite medicine with many; upon the belief 

1 In this country, at least, the introduction of bromide of potassium as an 
anti-epileptic may be credited to Dr. C. E. Brown-Sequard. 



232 DISEASES OF BRAIN AND NERVOUS SYSTEM. 

that it is a direct sedative to the excito-motor susceptibility of the 
medulla oblongata and other nerve-centres. From ten to twenty 
grains twice or thrice daily may be given, and continued for an inde- 
finite length of time. Bromide of ammonium (dose 10 grains) is 
spoken favorably of by some who have used it. 

Self-management is very important to the epileptic. Temperance, 
with nutritious diet, as the disease is one of asthenia, is necessary. 
Regularity of the evacuation of the bowels is a sine qua non. Abun- 
dant exercise in the open air, short of exhaustion, does good ; syste- 
matic gymnastics have even cured some cases. They are worth trying 
always. Avoidance of, or the extremest moderation in sexual inter- 
course must be insisted upon. Self-abuse will make recovery impos- 
sible. Tobacco ought not to be used, unless by smoking only a single 
pipe or a segar, or two, in the day. Coffee should not be recom- 
mended. 

It has already been implied, in referring to pathological views, that 
tracheotomy, suggested by Marshall Hall, and amputation of the 
limb in which the aura is felt, are useless although severe measures in 
epilepsy. 1 

A seton kept in the back of the neck is well worth trying in every 
case. I have known it to promote recovery. 

CATALEPSY. 

This is a periodical disease, in which the attack is marked by uncon- 
sciousness, and fixed rigidity of all or many of the voluntary muscles. 
It is rare. The attack generally lasts but a few minutes. Sometimes, 
in lunatics, a semi-cataleptic state of the muscles is permanent. 

I am not aware of any special treatment appropriate for this affec- 
tion. Management like that suitable for the epileptic will be in place 
also in catalepsy. Both are now so well understood to be asthenic 
disorders, with impaired hcematosis (blood-making) as an important 
element, that all reducing measures are properly omitted from their 
treatment. This must be essentially tonic and analeptic or restorative. 

CONVULSIONS. 

These may be classified as, principally, infantile, epileptic, par- 
turient and puerperal, hysterical and occasional convulsions. 

During infancy, causes which in an adult would cause delirium, 
produce convulsions ; excito-motor action having in early life the 
predominance. They are, usually, of less serious prognosis in the 
infant than in the adult. 

The exciting causes of infantile convulsions are numerous. Consti- 
pation of the bowels ; indigestion ; worms ; irritation of the gums in 
teething ; and excitement of the brain, as by fright, are about the 
most frequent. Many acute and chronic diseases of infancy (e. g. 
scarlet fever, meningitis, hooping-cough, etc.) have convulsions among 
their occasional symptoms or complications. Sudden drying up of 
eruptions on the scalp may bring them on, also. 



1 Another operation, clitoridectorny , practised by Baker Brown, of London, 
in certain cases in females, does not meet with general favor in the profession. 






CONVULSIONS. 233 

Premonition of a fit is often observed, in the child's fretfulness, or 
restlessness, or gritting of the teeth in sleep. AVhen a fit comes on, 
the muscles of the face twitch, the body becomes rigid at first, then 
in a state of twitching motion ; the head and neck are drawn backward, 
the limbs violently flexed and extended. Sometimes these movements 
are confined to certain muscles, or are limited to one side. Nurses 
call by the name of " inward fits" cases in which the limbs move but 
little, but the countenance is affected, the eyes are unnatural in ex- 
pression, or roll spasmodically, and the body is more or less rigid. 
During a fit, consciousness is absent. The eye shows no sign of sight, 
though open ; a finger passed over it does not make it wink. The 
pupil is immovably contracted or dilated ; the ear is insensible even 
to loud sounds. The pulse is small and very frequent ; breathing 
hurried or labored ; skin wet with perspiration, often cold and clammy. 
After this condition has lasted a few minutes it mostly gives way. 
The child falls into a quiet sleep ; or, it becomes conscious and 
bewildered ; or gradually resumes its ordinary healthy state ; or dies in 
the fit. Sometimes one attack is followed by another, with intervals 
of conscious or unconscious quiet between, for many hours. These 
are the most serious cases, although recovery often happens even 
from them. Salaam convulsions, or nodding convulsions of infants 
(eclampsia nutans), are a rare form of disease, usually the precursor 
of epilepsy. 

Treatment. — Ascertain, if possible, the cause of the convulsion. 
If the gums are swollen, or have been tender and irritated, at the time 
of teething, lance them freely; dividing the tense gum with a sharp 
gum-lancet down to the coming tooth. If the bowels have not been 
moved, or if the abdomen be swollen and tense, give at once an enema, 
of castor oil, soap, and molasses [F. 141], or some other laxative 
material, with warm water. When the head is hot, apply cold water 
all over it, by wet cloths, renewed every two or three minutes. If the 
fit lasts long enough for it, place the child in a warm bath ; supporting, 
of course, the head while the body is immersed. Then mustard 
plasters may be applied, to the back, epigastrium, and legs, at once 
or successively. 

Bleeding from the arm is to be recommended only in a child of 
known vigor and fulness of system, the attack being severe, and not 
habitual. But a moderate amount of blood should be taken. Cup- 
ping the back of the neck, in doubtful cases, where time is allowed by 
a protracted fit, may be resorted to. 

Etherization, so much used by some practitioners in puerperal 
convulsions, requires certainly more caution in its use in infant^. I 
have never tried it in the convulsions of childhood ; but would regard 
it as justifiable in an obstinate case at any age ; watching its effect. 

Convulsions of Pregnancy. — Probably about one pregnant woman, 
in fifty has more or less albuminuria ; principally from the pressure of 
the womb upon the renal veins producing congestion of the kidneys. 
About one in ten of these will have epileptiform convulsions, either 
during gestation, while in labor, or after delivery. 

Pathology. — All convulsions of pregnant women are not ursemic ; 
this has been proved. There are (putting aside instances of Bright's 
disease already existing) several conditions possible : 1. Uraemia, as 

20* 



234 DISEASES OF BRAIN AND NERVOUS SYSTEM. 

above stated ; 2. Cerebrospinal reflex irritation, of uterine origin ; 
3. Cerebro-spinal (apoplectic) congestion ; connected especially with 
the bearing down efforts of labor itself. 

Treatment. — It is important, particularly during gestation : 1. That 
plethora should be avoided ; 2. That free action of the kidneys, as 
well as regularity of the bowels, should be maintained. For the first, 
care of the diet is proper, that, in women of full habit, it be not too 
highly animalized or stimulant. If headache, with a full, hard pulse, 
occur, a mild cooling laxative may be given ; if not relieved, cups to 
the nucha or bleeding from the arm will be a safeguard. When urina- 
tion is not free and copious, even if no albumen appear in the urine, 
cream of tartar, a teaspoonful every day or two, or acetate of potassa, 
may be a useful prophylactic, by favoring free excretion from the 
kidney. 

When convulsions actually occur, in the pregnant or puerperal 
state, the question is to be considered — are they reflex, uraemic, or 
simply congestive or apoplectic ? 

When they come without previous signs of cerebral disturbance, 
but in a woman of delicate and impressible nervous organization, and 
without much heat of head, or snoring respiration, the pulse being 
rapid and feeble, it is probable that reflex irritation is the nature of 
the case. Counter-irritation, by dry cups to the spine and sinapisms 
to the epigastrium and limbs, and etherization, may be here used. 

When plethora has existed before, and the head is hot, its vessels 
distended, the coma profound, with snoring respiration and full, rather 
slow pulse, either uraemia or simple congestive apoplexy is to be con- 
cluded upon. In either case, but especially in the latter, bleeding 
from the arm, or by cups from the back of the neck or temples, will 
be advisable. Laxative enemata may also be used. After bleeding, 
if the convulsions are protracted, while the coma is less intense, careful 
inhalation of ether may be tried ; but it is less hopeful here. The 
prognosis of the apoplectiform convulsion is always one of great 
danger. The urcemic condition, if labor be survived, generally passes 
off spontaneously, soon after delivery. 

Occasional convulsions in adults, from whatever cause, should be 
studied and treated upon the same principles essentially as those just 
laid down for the convulsions of pregnancy. Hysterical convulsions 
will be considered under Hysteria. 

CHOREA. 

Synonym. — St. Vitus' Dance. 

Symptoms. — Incessant and irregular movements of the voluntary 
muscles, over which the will has but partial control. Walking, in 
severe cases, is difficult or unsafe ; the hands cannot be regulated 
enough to write or work ; speech may be affected ; the muscles of the 
face often twitch grotesquely. During sleep all these movements cease. 
The pupil is, in some cases, unnaturally dilated ; palpitation of the 
heart may occur ; and also constipation and indigestion. The urine 
is of great density. 

Prognosis. — The mean duration of chorea is about four weeks ; but 






TETANUS. 235 

it may last for several months. Recovery, if the attack be uncompli- 
cated, may always be anticipated. 

Complications. — Endocarditis and pericarditis have been observed 
in connection with chorea in a number of cases. Generally, however, 
the affection of the heart precedes the chorea ; both probably depending 
upon the same cause, rheumatism. 

Paralysis complicating chorea increases greatly, of course, the 
seriousness of the case. Although it may be of the transient, hysteri- 
cal form, yet the danger exists that it may be the result of organic 
lesion (as softening) of the brain or spinal cord. 

Causation. — From six to sixteen, in both sexes, especially often, 
however, in girls, chorea occurs. Nervous debility is nearly always 
present before the attack. Fright is a frequent cause. Over fatigue, 
or mental excitement, blows or falls may produce it. Rheumatic fever 
is sometimes followed by it. 

Treatment. — Good diet, salt bathing, and systematic gymnastic 
exercises (light gymnastics or calisthenics) will suffice for mild cases. 
Where marked anaemia exists, iron (citrate, phosphate, [F. 142], or 
pyrophosphate, tincture of chloride, liquor of iodide) is important. 
Obstinate cases may be treated with Fowler's solution of arsenic, in 
small doses, gradually increased. Cimicifuga has been a good deal 
used, perhaps with benefit. Cod-liver oil should be given if great 
debility exist. Calabar bean has recently been introduced as a remedy 
in chorea ; f ^ss of the tincture, or from gr. j to gr. vj of the powder 
thrice daily. 

It is well to separate a child having severe chorea from other 
children ; both because of the annoyance of their curiosity, and because 
sympathetic irritation sometimes extends the affection from one to 
another. This has been repeatedly observed. 

TETANUS. 

Definition. — A disease characterized by continued tonic contrac- 
tion of the voluntary muscles generally. 

Symptoms. — Stiffness of the muscles of the jaws commonly begins 
the attack. This extends to the throat and neck, face, trunk, and 
lastly to the limbs. Though never ceasing entirely, the spasm of the 
muscles is paroxysmally increased. Sometimes opisthotonos occurs, 
t. e., arching of the body upon the back and heels, the abdomen pro- 
jecting ; or emprosthotonos, arching forward, the face approaching 
towards the toes. Pleurosthotonos, or lateral curvature, is much 
more uncommon. . 

Chewing of food is impossible ; swallowing nearly or quite so ; respi- 
ration becomes very difficult. The patient suffers dreadfully, and 
cannot sleep ; but delirium scarcely ever occurs. Death in most 
cases takes place within a week. 

Varieties. — These are, tetanus from cold (idiopathic), traumatic 
tetanus (from an injury), and trismus naseentium, or tetanus of 
infancy. The first is the least certain to be fatal. 

Causation. — This is principally included in the above. Much the 
greater number of cases results from lacerated and punctured wounds ; 
but .amputations and other operations may be followed by tetanus. 



230 DISEASES OF BRAIN AND NERVOUS SYSTEM. 

Irritation (not inflammation) of the ends of sensitive nerves, trans- 
mitted to the spinal cord, produces the reflex spasm, whose general 
extension and continuance proves fatal. Strychnia, in poisonous 
doses, causes a very similar state. While there can be no doubt that 
the spinal marrow is the seat of the disease, no characteristic organic 
change has been found in it; sometimes not even congestion. 

Treatment. — In two cases which I have seen to recover, opium and 
brandy were the remedies used. A tablespoonful of brandy (to an 
adult) every two or three hours, with milk or beef-tea, and a grain of 
opium every three or four hours, may be given. The opium may be, 
if needful, increased to a grain every hour at night, and every two 
hours through the day. Beyond that I would not go. 

Chloroform and other anaesthetics, by inhalation, have been tried, 
with variable effect; nearly always without success. Belladonna, 
aconite, hydrocyanic acid, cannabis indica, tobacco, woorara, and 
quinine, are among the many medicines favored by different practition- 
ers. In so desperate a disease it is excusable to give them all further 
trial. My father, Dr. Joseph Hartshorne, used vigorous counter- 
irritation all along the spine, by the decoction of cantharides in 
turpentine (linimentum cantharidis). 

HYDROPHOBIA. 

I have known a physician of distinction and of many years' practice 
to deny the existence of hydrophobia because he had not seen it ; 
asserting that the cases so called were tetanus. I have seen two cases 
of it ; and no one who has observed it can fail to perceive the wide 
distinction between it and tetanus. 

Symptoms. — A month or more after the bite of a mad dog or other 
rabid auimal, the wound having healed, irritation is felt in it. Nervous 
restlessness also exists ; which increases (in most cases) to violent, 
angry delirium. Then difficulty of swallowing occurs, from a spasm 
of the muscles of inspiration (gasping) taking place at the moment of 
deglutition, making the patient choke. The same spasmodic gasping 
is brought on by any sudden impression ; as of sound, a flash of light, 
or even a current of air passing over the face. Insomnia exists ; the 
patient grows prostrate, and must die for want of food and drink, 
even if the affection of the cerebro-spinal axis were not itself fatal. 
There is intense thirst, and no dread of water, except that the attempt 
to swallow it causes distress. Death occurs in from four to eight or 
ten days. 

I have not met with satisfactory evidence that a case of genuine 
rabies canina or hydrophobia has ever been cured. By statistics, 
however, only one in eleven (some say one in five) of those bitten by 
mad dogs have the disease, even when no precaution is taken. 

Treatment. — If we cannot cure, what can or should we do ? We 
may certainly promote at least euthanasia, by allaying the wretched 
sufferings of the patient. In the case of a boy of eight years of age 
under my own care, I administered chloroform freely by inhalation; 
continuing it nearly all the time (with short intervals and equally short 
applications) for two days and nights. It mitigated the spasms and 
quieted the delirium. That it did not itself cause death (as might 



HYSTERIA. 23T 

have been suspected from the quantity used) was proved to my satis- 
faction by the fact that after the chloroform was finally withdrawn, 
the boy was made to gasp spasmodically by waving the hand to and 
fro over his face. Eeflex excitability of the medulla oblongata was 
thus shown still to exist. 

Hypodermic injection of atropia or morphia might, perhaps, more 
effectually quiet the suffering, and even afford a possibility of cure, 
than inhalation of anaesthetics. 

Prophylaxis. — The only perfect safety to one who is bitten by a 
rabid animal (and the bite of a much enraged dog, not rabid, is said 
to have also caused hydrophobia) is in immediate and total excision 
of the part. While awaiting this, forcible suction will aid in remov- 
ing the poison ; and ligation with any kind of bandage above the part 
will retard the absorption of it. When excision cannot be safely per- 
formed or is refused, cauterization is the next best thing. Free ap- 
plication of lunar caustic is recommended. Even if the person bitten 
is not seen until a day or two afterwards, excision or the use of the 
caustic is to be recommended, as lessening the danger of this horrible 
disease. 

It is well to know that canine madness is not restricted to, nor even 
especially frequent in, hot weather. 

HYSTERIA. 

From its occurring nearly always in females, and from a supposition 
of its originating in some affection of the womb, this name has been 
given to a variable disorder, of which the main characteristic is, mor- 
bid excitability of the whole nervous system. 

A " fit of hysterics " is a paroxysm whose nature may vary, from 
mere uncontrollable laughter or crying, to a severe epileptiform con- 
vulsion. This last, however, differs from epilepsy, in there being less 
complete loss of consciousness, and in its curability. It is often pre- 
ceded by a sensation (globus hystericus) like that of a ball rising 
towards the throat. 

Simulation of other diseases, indeed the assumption of severe func- 
tional disorders of different organs, is a common trait of hysteria. Thus 
I have seen hysterical amaurosis ; hysterical insanity is not uncommon ; 
nor is hysterical paraplegia or coma rare. Retention of urine, cough, 
aphonia, &c, are often thus produced. " Phantom tumor " is among 
the most curious of such things. I had in my care a woman who had 
been laid out by a surgeon in another city for exploratory gastrotomy, 
upon the supposition that she had ovarian tumor. When she was 
etherized, however, the tumor altogether disappeared! " Bed case" 
is the name given to the complaint of a hysterical valetudinarian, who 
believes herself to be ill or powerless, while there is really nothing 
the matter, except the morbid neurosis itself. 

Treatment. — Much skill and care will often be required in the 
management of hysteria ; as each case has peculiarities of its own. 
Generally, a tonic regimen is demanded. Iron and cod-liver oil are 
most often the appropriate medicines. Bromide of potassium is some- 
times quite useful. For a paroxysm of " hysterics," assafcetida [F. 
143] is universally safe and suitable ; in pills of three grains each, pro 



238 DISEASES OF BRAIN AND NERVOUS SYSTEM. 

re nata. Sinapisms and pediluvia are also proper. Menstruation is 
often irregular in hysterical women ; it should be regulated as far as 
possible. Exercise in the open air is, as a rule, very important for 
such persons. Mental and emotional excitement should be avoided ; 
but tranquil, even engrossing occupation will be beneficial. For 
hysterical paralysis, electricity is said to be promptly useful. Cold 
bathing, especially the shower bath, or sea bathing, when followed by 
reaction, will do good. Feeble and delicate persons should, however, 
be careful not to remain in the bath too long. In the surf, for ex- 
ample, a bath of five or ten or fifteen minutes may be of great service, 
when a longer time would do real harm. 

NEURALGIA. 

Definition. — Pain, without inflammation or other disorder, except 
that of the nerve or nerve-centre involved ; literally, nerve-pain. 

This may affect any of the sensitive nerves. It is, also, sometimes 
referred to parts which have, in health, no sensibility ; as the heart, 
stomach, &c. Different names are given according to its site. Thus, 
tic douloureux is facial neuralgia ; hemicrania, that affecting one side 
of the head ; sciatica, that of the hip ; gastrodynia, neuralgic pain in 
the stomach ; pleurodynia, in the side. Angina pectoris is, chiefly, a 
neuralgic affection of the heart. 

The pain is generally acute, shooting, or darting ; with tenderness 
of the part upon pressure. There is, however, no heat nor swelling, 
nor throbbing of the bloodvessels in pure neuralgia. Complicated 
cases occur, in which inflammation and neuralgia exist together ; 
and inflammation of the fibrous neurilemma may be the immediate 
cause of the neuralgic pain. 

Pathology. — At least three sources of this sort of pain are possi- 
ble. 1. Local disease affecting a nerve ; 2. A morbid state of a sen- 
sorial nerve-centre ; 3. A morbid condition of the blood. Neuralgia 
always fixed or returning in the same spot, is likely, although not 
certain, to depend upon a fault in the nerve itself; as e. g. neuroma 
(tumor of a nerve). Radiating pain (although possibly of reflex 
origin) must involve at least part of a nerve-centre. Flying pains, 
never long seated in one part of the body, mostly are due to a defect, 
or morbid poison (as that of gout, or malaria) in the blood. 

Treatment. — This must, of course, depend upon the cause or 
nature of the case. Tic douloureux often depends upon decay of the 
teeth ; if so, they must be attended to. Other purely local neuralgias 
require local treatment. Even division of the affected nerve is some- 
times, but should rarely be, resorted to. Laudanum or paregoric, 
applied by saturating a rag and laying it upon the part, covered by 
oiled silk to prevent evaporation, is an efficient local anodyne. So is 
chloroform, similarly applied ; it is very pungent, burning like mus- 
tard. Sinapisms will sometimes relieve promptly. Mere warmth, as 
of flannel steeped in hot water, will do so in some instances. Rubbing 
for a few minutes with saturated tincture of aconite root, until the 
skin tingles ; or the application of ointment of veratria (gr. xx in gj 
of lard), may be used in severe cases. In the most obstinate ones, a 
blister may be applied, dressed, after removal of the cuticle, with two 



DELIRIUM TREMENS. 239 

grains of acetate of morphia, diluted with ten grains of gum Arabic. 
Or, most prompt usually of all, solution of morphia may be hypoder- 
mically injected, to the amount of one-fourth drachm to one drachm 
at once. Sometimes the inhalation of ether, nitrous oxide, or chlo- 
roform is resorted to, for the relief of intense neuralgic pain. De- 
bility predisposing to it, in some cases moderate doses of some alcoholic 
stimulant will give relief. 

Of anodynes internally used, belladonna has, for neuralgia, the 
greatest reputation. It will not quell suffering so directly as opium 
or morphia, but it has been thought more entirely to do away with 
the neuralgic state. For this, however, iron, especially in combina- 
tion with quinia or strychnia, is the most effective medicine. Cases of 
neuralgia which will not be benefited by iron are decidedly excep- 
tional. Larger doses of it are generally recommended for this than 
for other cases requiring chalybeates. Quinine is particularly wanted 
in neuralgias of malarial orign (very common) ; and strychnia or nux 
vomica in those whose obstinate persistence depends upon great loss 
of nervous energy. Everything that recuperates, as generous diet, 
change of air, sea-bathing, &c, will assist in curing neuralgia, when 
it is connected, as it so often is, with anaemia and broken health. 

Odontalgia, toothache, is sometimes purely neuralgic. More often, 
it results from exposure of the nerve by the decay of the tooth. 
Again, it may attend inflammation of the jaw, or abscess at the root 
of the tooth affected. For toothache from exposed nerve, creasote is 
a certain remedy. Insert carefully into the hollow a plug of cotton, 
wrapped over the end of a knitting needle and dipped in pure crea- 
sote. If the latter run out into the mouth (which should be avoided 
if possible) rinse it at once with cold water. 

DELIRIUM TREMENS. 

Synonym. — Mania a potib. 

Symptoms. — Sleeplessness, debility, tremors, horror, hallucina- 
tions ; often with loss of digestive power. The insomnia is a cardinal 
symptom ; if the patient sleeps a whole night he recovers. Debility 
varies in degree in different cases ; in a first attack it is not always 
great. Tremor is nearly always present. The illusions of the patient 
are wonderfully real, and generally dreadful. He is pursued by 
demons or beset by mortal enemies ; he cannot bear to be alone, espe- 
cially in the dark. Sometimes, however, the visions are indifferent, 
or even amusing. The patient may suppose himself to be well, and 
engaged about his usual avocation ; going through all its movements 
in pantomime, though with empty hands. 

After several days and nights of sleeplessness, prostration usually 
increases ; the skin grows cold and clammy, the voice feeble, and the 
patient no longer inclines to move about. Death must result, if sleep 
be not obtained, within a week, or, at the most, two weeks. In favor- 
able cases, a sound sleep of many hours comes on within three or 
four days ; the patient then wakes up rational and well. 

Causes. — There is no room for doubt that this affection may come 
on under two different conditions or circumstances : 1. where stimu- 
lants are suddenly withdrawn from one accustomed to them ; and 2. 



240 DISEASES OF BRAIN AND NERVOUS SYSTEM. 

while their use in excess is continued. The second class, according 
to my observation, furnishes the most dangerous cases. 

Treatment. — Old as this disease is, it is yet the subject of great 
difference of opinion. The practice which early training led me to 
adopt, consisted in the moderate use of stimulants (" tapering off") 
and of opium, with concentrated liquid nourishment. If the patient 
was not much prostrated, I would give only ale or porter, a bottle or 
two in the day ; with hop tea ad libitum, and a grain of opium every 
three or four hours. The latter would be increased, if sleep were 
delayed, to a grain every two hours ; or, as a maximum, a grain every 
hour. Yery weak cases, accustomed to spirits, might have a table- 
spoonful of whisky or brandy every four, three, or two hours, accord- 
ing to their condition. Beef-tea and mutton-broth, &c, seasoned with 
red pepper, are preferred as diet. In an obstinate case, I have seen 
sleep follow the raising of a blister upon the back of the neck. Sub- 
stituting valerian for opium, or combining the fluid extract or tincture 
of valerian with morphia solution, has answered well in some cases. 
[F. 144, 145]. Injection of laudanum into the rectum is occasionally 
resorted to. 

Other modes of treatment have recently been urged. 1st. The 
expectant treatment, of Drs. Dunglison and Laycock ; giving only 
strong food, without stimulants or opium. 2d. The treatment of 
tablespoonful doses of tincture of digitalis. 3d. That by the internal 
use of chloroform, in one or two drachm doses. 

The expectant treatment will no doubt do very well in mild or 
moderate cases. From what I have seen, I should fear to trust to it 
in severe or threatening ones. 

The digitalis treatment, bold as it seems, has a good deal of posi- 
tive testimony in its favor. Why not try, as some do, less immense, 
and yet large, doses ; as half a drachm or a drachm, instead of half an 
ounce, of the tincture, every three or four hours ? 

Dr. E. McOlellan and others have recently reported excellent suc- 
cess with one or two drachm doses of undiluted chloroform. The 
corrugated stomach of a spirit drinker will probably bear the pungency 
of chloroform better than another's. Generally only one or two such 
doses of it are said to be required. My experience with the internal 
use of chloroform leads me to believe such practice perfectly safe, at 
least. It is well worthy of further trial. 

The large majority of first attacks of mania a potft are curable. 
Third and fourth attacks are often fatal, or are followed by permanent 
insanity. 

METHOMANIA. 

Definition. — The disease of uncontrollable or irresistible intem- 
perance. 

Synonyms. — Dipsomania ; Oinomania. 

Varieties. — Periodical or paroxysmal, and chronic or persistent 
methomania. The subject of the first may be temperate for weeks or 
months, and then will abandon himself to violent excess for some days 
or for a week or two. The persistent methomaniac is constantly 
intemperate, so long as the opportunity exists. 



INSANITY. 241 

Causes. — Hereditary proclivity exists in many cases. Wilful or 
unwise excess is the cause, of course, of intemperance in every case. 
To designate it as a disease is not at all to deny the accountability of 
those who voluntarily incur it ; only thus its true character of uncon- 
trollableness (in many instances) by the will is indicated. That any 
intrinsic power exists in alcohol, employed for its proper needs as a 
medicine, and in proper quantities, to bring on intemperance, I do not 
believe. I have known too much of its use in practice in low fevers, 
in phthisis, and many other conditions of debility, not to be sure that 
it is only when used in excess, or out of place, that any hankering or 
slavish demand for it is begotten. 

Treatment. — No safety exists but in seclusion, for a year or two, 
where the individual cannot obtain stimulus, and is not made, by 
company or opportunity, to desire it. Laws should be made by which 
every person, proved upon inquiry before a commission, to be habitu- 
ally intemperate, should (like a lunatic) be deprived of the control of 
his liberty and property. Then in every community there ought to 
be institutions where a safe and home-like retreat could be had, for a 
sufficient time to restore self-control ; which, I repeat, ought to be 
never less than a year ; better, two years. Such institutions exist now 
in New York and Massachusetts ; and, with the encouragement of 
recent improvements in legislation, one is about to be established in 
this State, near Philadelphia. 

INSANITY. 

Definition. — Loss of control of the will over the mental faculties 
or impulses ; intellectual, emotional, or sensorial derangement. 

Varieties. — 1. Mania; acute 1 and chronic; also divisible into 
intellectual insanity or delusion, emotional or moral insanity, and 
illusional derangement or hallucination. 2. Monomania, or partial 
insanity ; e. g., homicidal and suicidal ; kleptomania, or insane pro- 
pensity to steal; erotomania (satyriasis, nymphomania), or uncontrol- 
lable amatory desire ; pyromania, morbid propensity to commit arson, 
etc. 3. Melancholia. 4. Dementia; t. e., total wreck of the 
faculties, or imbecility. Idiocy is congenital imbecility. 

Premonitions. — By noticing these, often prevention may be sug- 
gested and effected. Hardly any of them alone may be sufficient, 
while all together they become so. 1. Headache, not accounted for 
by ordinary causes, and continuing for days or weeks together. 2. 
Irritability of temper, not previously habitual. 3. Unnatural hilarity, 
without occasion. 4. Depression or gloom, not justified by any event. 
5. Alternations of excitement and despondency, both extreme. 6. 
Any great modification of the natural temper or habit of mind, so 
that the individual becomes the opposite of his usual self. 7. Dislike 
or distrust of near friends and family, without any reason for it. 

Diagnosis. — Alienation from his own accustomed character, and 
disruption from rational and harmonious relations with persons and 
things around him ; these are the cardinal elements of the insane state. 
This, all authorities admit to be more easily detected or discriminated 

1 Puerperal insanity is one form of acute mania. 
21 



242 DISEASES OF BRAIN AND NERVOUS SYSTEM. 

than defined. The old legal test, that the lunatic must be incapable 
of knowing right from wrong, must be given up ; as very many cases 
of emotional or ''moral" insanity are proved to exist, in which, with 
full knowledge of right and wrong, the morbid impulse is irresistible 
by the will. There is no 'physical test of insanity, by the pulse or 
otherwise ; as in chronic mania, &c., all the organic functions may go 
on normally. The expression of the face is, it is true, nearly always 
unnatural. Perhaps the greatest difficulty sometimes exists in mono- 
mania, unless one knows the peculiar delusion or morbid proclivity of 
the patient ; as, upon all other matters, he may be sound. Feigned 
insanity is generally over-acted ; sometimes it may require the skill of 
experts to expose it. 

Prognosis. — More than half of first attacks of insanity, under good 
management, are recovered from. With each repetition, the hope 
grows less ; and so it does, also, in proportion to the duration of 
chronic mania. Sometimes, however, cures occur of those who have 
been insane for years. Dementia is a common, and generally hope- 
less, termination of prolonged chronic mania or melancholia. Puer- 
peral mania is curable in a large majority of cases. Ordinary acute 
mania varies in duration from a week or two to several months. 
It may end either in recovery, in lapsing into chronic mania, in de- 
mentia, or even in death during the attacks. Periodical insanity 
is occasionally met with, especially in females. 

Causes. — These are numerous. The principal ones are, hereditary 
predisposition, injuries of the head, intemperance, reverses of fortune, 
loss of friends, and domestic troubles. 

Pathology. — Much yet remains to be learned of this. Subtle 
alterations of the brain structure are still to a considerable extent un- 
recognizable, even with the aid of the microscope. Two elements in 
the pathology of insanity have, at least, been distinctly made out ; 
cerebral hyperemia, which predominates in the more acute cases, and 
atrophy, which is (either quantitative or qualitative) present in nearly 
all those which are chronic. 

For the treatment of insanity it is proper to refer to special trea- 
tises upon the subject. (See Bucknill and Tuke on Insanity.) The 
advice of a physician, in nearly every case, ought to be, early removal 
to a well conducted asylum or hospital for the insane. There, secu- 
rity, and the prospect of recovery, will be much better than at home, 
though amongst the kindest of friends. In the treatment of insanity, 
in recent times, while medicine (especially tonics and anodynes) is not 
neglected, the tendency is to confide a great deal in moral or mental 
treatment ; i. e., the aggregate of personal, local, and circumstantial 
influences, which, in an asylum, can be arranged especially with a view 
to the most favorable effect upon its inmates. 

HEMORRHAGES. 

Varieties. — 1. Active; 2. Passive; 3. Traumatic; 4. Symptoma- 
tic ; 5. Critical ; 6. Vicarious. Local hemorrhages are also classified 
according to the organ from which the blood escapes. 

Active hemorrhages are those in which determination of blood in 
excess to the part precedes the bleeding. Passive hemorrhages, 






HEMORRHAGES. '243 

those in which, from inaction of the circulation, or dilatation 

of bloodv.; - 5 :ion occurs : or in which the coats of the v 

give way too readily, partly from the blood itself being incapable of 
maintaining properly their nutrition. The idea of bleeding by 
halation n without rupture at least of capillaries, is now abandoned. 

Traumatic hemorrhages are. of course, all produced by wounds : 
coming thus under the department of surgery. 

Symptomatic hemorrhages are met with in many disea- 
epistaxis in typhoid fever: haemoptysis in consumption: vomiting of 
blood in cancer of the stomach ; bleeding from the bowels in pile- 
Critical hemorrhages are occasional terminations of febrile dis- 
orders : as yellow fever, remittent fever. Vicarious hemorrhage is 
that which substitutes one which is normal or habitual : ::ting 

of blood when the menses have been suppressed: or bleeding at the 
ig arrest of the bleeding of habitual haemorrho: 

Epistaxis. — By usage, this term is applied only to bleeding from 
the nose. In young persons, especially from ten to fifteen years of 
it is common, and. if moderate, harm'; zing often to relieve 

a temporary coi I and prevent a headache. It is more often 

seriously troublesome in older persons. Generally it is from one nos- 
tril only, but not always. 

Treatment. — When slight, it may be allowed to stop of itself: only 
not blowing away the clot that forms as a natural plug. If it con- 
tinue so as to threaten an injurious loss of blood, applying cold w 
to the forehead and nose, or ice. there or to the back of the neck, or 
to the roof of the mouth, will generally stop it. If not. a plug of dry 
cotton may be introduced and left in the bleeding nostril. TTetting 
the cotton first in strong alum-water, or dilute tincture of chloride of 
iron, or dipping it in powder of tannin or matico may make it more 
effective. When these measures fail, the posterior nares must be 
plugged. Either the watch spring canula may be used, or an elastic 
catheter, having a piece of waxed ligature or U -ed through its 

eyelet hole, may be carried back from the nostril to the pharynx. 
Then the string should be drawn out of the mouth with forceps, a plug 
of cotton fastened to it. and the other end of the string drawn out 
through the end of the catheter till it forces the cotton plug against 
the posterior orifice of the nares. Baising the arms high above the 
head is a popular mode if p nose-bleeding. 

Bleeding from the Mouth. — This, unless when ulcerative, is gene- 
rally from the gums ; as in scurvy. It is. in itself, scarcely ever 
serious in amount. Considerable bleeding, sometimes hard to b 
may occasionally follow the extraction of a tooth. 

Treatment. — Borax in solution, or tannic acid, or myrrh and : 
water, will be suitable^ for the bleeding and spongy gums of 

scurvy. For hemorrhage after the removal of a tooth, it may be 
^ary to plug the cavity with lint or cotton dipped in tincture of 
chloride of iron, or creas 

Haemoptysis. — This term (spitting of blood) is generally applied 
to hemorrhage from the lungs, bronchial tubes, trachea, or larynx. 
Ulceration of the larynx, trachea, or bronchi may produce it. not often 
dangerously. I remember one case, in which ulceration of the larynx 
extended so as to open the carotid artery, with fatal result, II 



244 HEMORRHAGES. 

often the source of the blood is the lungs. The diagnosis of this is 
of great consequence. I have known much alarm to be produced 
by the spitting of blood whose source examination proved to be 
the posterior nares. This was not supposed by the patient, because 
there was no bleeding anteriorly from the nose. Between pulmonary 
hemorrhage and that from the stomach, the following contrast of signs 
exists : — 

From the Lungs. From the Stomach. 

Dyspnoea. Nausea. 

Blood coughed up. Blood vomited. 

" florid, sometimes frothy. " dark, not frothy. 

" mixed with sputa. " mixed with food. 

In a majority of instances, spitting of blood from the lungs is a 
symptom of phthisis. Cases occur, however, sometimes, especially 
during adolescence and early maturity (from 18 to 30 years of age) of 
more or less active pulmonary hemorrhage, whose subsequent history 
disproves a tuberculous origin for it. In these cases, there may be 
immediate danger, more probably than in the frequent bleedings of 
consumption. Aneurism of the aorta may also cause haemoptysis, 
by rupture of the tumor, which must cause death. This of course is 
rare, and is made known by signs already considered. 

Treatment. — For active, congestive pulmonary hemorrhage, in a 
young and robust person, it was formerly the common practice to 
take blood from the arm, as a derivant measure. I have known this 
to succeed perfectly, with no subsequent disadvantage. But, dry 
cupping over the chest and back, with sinapisms to the legs, and ice, 
salt, or alum, swallowed slowly, the patient being at perfect rest in 
bed, with the head and shoulders raised, will be sufficient treatment 
at the start for most cases. Then we should prescribe, if the bleed- 
ing continue after the first gush, acetate of lead with opium in pill; 
say a grain or two of the former with half a grain of the latter every 
four, three, or two hours as the case needs, for a day or two. 

In passive, or tuberculous haemoptysis, rest, with the head and 
shoulders propped, is also necessary. Ice, salt, and alum, alone or 
together, may be held in the mouth and swallowed very slowly, till the 
bleeding has stopped for the time. For medicines, in the anaemic, 
gallic acid (gr. x to gr. xxx, in solution with aromatic sulphuric 
acid) [F. 146], oil of turpentine (gtt. x to gtt xx, in mucilage) [F. 
147], and ammonio-ferric alum (gr. v to gr. x), or tincture of chloride 
of iron, are most recommended. But dosing with these styptics in con- 
sumption is not proper for every trifling discharge of blood. They are 
suitable only when the hemorrhage itself is, or threatens to be, a source 
of additional debility. 

Pulmonary Apoplexy. — This is the extremest degree or result of 
congestion of the lungs ; hemorrhage occurring into the air-cells, and 
obstructing respiration, sometimes to a fatal degree. Disease of the 
heart predisposes to this. Its attack is apt to be somewhat sudden ; 
there is great dyspnoea, with a purple countenance, and skin rather 
cold. Percussion resonance is dull. On auscultation, at first, a bub- 
bling or mucous rale is heard ; after the blood coagulates, no respira- 
tory sound at all. 






HEMORRHAGES. 245 

Treatment. — If diagnosticated early, in a person of tolerable 
strength, venesection should be performed at once. Then (or instead, 
in a feebler subject) dry or cut cups should be applied extensively 
between the shoulders ; followed by a large sinapism over the anterior 
part of the chest, and a hot pediluvium. At the same time the reaction 
which should aid in unloading the oppressed lungs (the object of vene- 
section, cupping, &c.) may need to be favored by hot drinks, as hot 
lemonade, carbonate of ammonia, or, if coldness be decided, whisky 
punch. 

Haematemesis. — Vomiting of blood may result from cancer, or ulcer 
of the stomach, congestion of the liver, aneurism of the abdominal 
aorta, &c. We have given, above, the distinguishing signs between it 
and haemoptysis. 

Treatment. — Of course this must be varied according to the cause. 
Slight ejections of blood from the stomach may not of themselves 
require treatment — having only a diagnostic importance. In ulcer of 
the stomach the greatest danger may occur, except from rupture of 
an aneurism. In copious haematemesis, with absolute rest in the 
horizontal position, ice, creasote (one or two drops, pro re nata), in 
solution, or pills [F. 81], gallic acid [F. 146], oil of turpentine [P. 
147], ammonio-ferric alum, or tincture of chloride of iron, may be pre- 
scribed. Food must be given in small quantities, and concentrated. 

Haematuria. — This may be either from the kidneys or from the 
bladder. If the blood is thoroughly mixed with the urine, it is probably 
renal. If the water flows off nearly pure, and the blood follows or accom- 
panies the last portion, it is vesical. When it follows the use of a 
catheter or bougie, independently of urination, and flows in a stream 
or in fresh drops, it is urethral and traumatic. 

Renal hemorrhage may attend congestion or inflammation of the 
kidney; or cancer ; or scarlet fever (generally a late stage) ; or the 
irritation of a calculus ; or that of cantharides or turpentine ; or, in 
old persons, it may be passive. In Egypt, a parasite sometimes pro- 
duces it; the distoma haematobium. 

Treatment. — For hemorrhage from the kidney sufficient to deplete 
at all seriously, astringents, as gallic acid, tincture of chloride of iron, 
alum, or acetate of lead, may be used. Rest is important, in this as 
in all hemorrhages, during the attack. Bleeding from the bladder may 
be treated by the injection, through a catheter, of solution of alum or 
dilute solution of creasote (gtt. j in fgj of water) or tannic acid (gr. 
xinfgj). 

Intestinal Hemorrhage. — The causes of this are, especially, 
typhoid fever, of which it is sometimes symptomatic, and occasionally 
critical ; i. e., the commencement of convalescence. The same may 
occur in yellow fever, or in remittent fever (less often). Aneurism of 
the aorta, congestion of the liver, abdominal cancer, may cause it. 
Blood is passed, commonly in small quantity, with the discharges of 
dysentery. Aged persons not unfrequently have passive hemorrhage 
from the intestines. Internal piles are very often productive of it. 
The blood from the latter is bright red; other bleeding from the 
bowels is darker and more mixed. 

Treatment. — Acetate of lead, by the mouth, with opium, or by 
enema ; tannic or gallic acid, in pill or by injection in solution ; oil of 

21* 



246 DROPSIES. 

turpentine ; cveasote, and tincture of chloride of iron, or ammonio- 
ferric alum, are here, as in the other hemorrhages mentioned, the most 
reliable astringents. For bleeding piles, special treatment has already 
been alluded to. 

Vicarious Hemorrhage. — The most frequent instances of this are 
in connection with suppressed menstruation. Epistaxis, haemoptysis, 
haematemesis, renal or intestinal hemorrhage may occur, but it is most 
apt to be from the stomach or lungs. The prognosis in this form of 
hemorrhage is much less serious than in the same of other origin. Its 
treatment should be addressed mainly to the regulation of the dis- 
turbed or interrupted uterine function. Warmth to the lower extremi- 
ties and back, with such emmenagogues as each case may indicate, will 
generally be required. Astringents are to be avoided in vicarious 
hemorrhage, unless it be in excess of the ordinary menstrual or other 
suppressed discharge. 

Uterine Hemorrhage. — Besides simply excessive menstruation, 
uterine hemorrhage may be from placenta praevia (" unavoidable hemor- 
rhage") ; abortion ; subsequent to delivery ; uterine cancer ; ulceration 
of the os or cervix uteri ; tumors within, or in the walls of, the womb. 

Treatment. — In considerable uterine hemorrhage, of either variety, 
ergot, in substance or the wine, is likely to be of use by promoting 
contraction of the womb. Ammonio-ferric alum is also a good medi- 
cine to give by the mouth in the same case. Locally, ice or iced 
water may be (with care not to chill too much) applied for a short 
time over the hypogastric region, or thrown into the vagina. Tincture 
of chloride of iron, in strong solution, will have a powerful effect. 
Tannic acid or matico may be likewise applied ; or the " styptic rod " 
of tannic acid and cocoa butter, shaped to fill the vagina. But 
threatening cases (except post partum) may require the actual tampon, 
or plug of lint for the whole vagina, or the sponge-tent inserted into 
the os uteri itself. Stimulants may at times be called for to prevent 
fatal exhaustion under large hemorrhage, either from the uterus or 
from any other organ. Pressure upon the aorta has been sometimes 
resorted to, through the abdominal walls, in uterine hemorrhage. 
Other measures, suitable after delivery, belong to the department of 
obstetrics. 

Habitually excessive menstruation requires that the patient so 
affected should maintain absolute rest, from the beginning of the flow 
till its cessation. Iron is nearly always indicated in such cases, 
through the interval ; particularly the tincture of the chloride of iron. 



DROPSICAL AFFECTIONS. 

Varieties. — 1. (Edema, local infiltration of connective tissue with 
serum. 2. Anasarca, general cellular dropsy. 3. Hydrocephalus. 
4. Hydrothorax. 5. Hydropericardium. 6. Ascites. 7. Other local 
dropsies ; as Ovarian dropsy, Hydronephrosis, Hydrocele of the 
testis, etc. 

Causation and Pathology. — Obstruction to the venous circulation, 
arrest of excretion and absorption, and excess of water in the blood, 
are the three cardinal elements of the pathological causation of dropsy. 



DROPSIES. 247 

Either one may induce it. Disease of the heart or of the liver brings 
on dropsy by venous obstruction. Disease of the kidney, or the action 
of cold and wet upon the skin, may produce it by checking excretion. 
Wasting diseases are liable in their advanced stages to oedema and 
anasarca, on account of the watery state of the blood. 

Acute general dropsy results from the powerful impression of cold 
and wet, or of the scarlet fever poison, upon the system; suppressing 
both the action of the kidneys and that of the skin at once. Its most 
common form is anasarca ; but it may take that of ascites, hydrothorax, 
or even hydrocephalus. When from cold and wet, it is much more 
curable (especially anasarca or ascites) than similar dropsy of visceral 
origin, e. g. from disease of the heart. Albuminous urine is quite 
common in acute general dropsy. 

Hydrocephalus, Hydropericardium, and Hydrothorax have been 
already sufficiently considered. 

Ascites : peritoneal dropsy ; accumulation of water in the abdomen. 
The causes of this of greatest frequency are, cirrhosis of the liver, and 
disease of the kidney. It may also follow obstruction of the portal 
vein by cancer, or general obstruction of the circulation from disease 
of the heart, aorta, or spleen ; and it is sometimes ascribed to chronic 
peritonitis. 

Symptoms and Diagnosis. — Often with emaciation of the face, 
neck, and arms, there is great enlargement of the abdomen. When 
this is far advanced, orthopnoea exists, from pressure upon the dia- 
phragm. The patient is generally weak, with poor appetite and 
deficient rest at night. 

On inspection, in the upright posture, the fulness is greatest in the 
lower part of the abdomen; when recumbent, it spreads evenly; on 
one side, it falls over that way. Palpation will make evident Jluctua- 
tion, especially when one hand is placed on one side of the abdomen 
and the other strikes gently, at a distance of a few inches. Percussion 
discovers resonance above and about the umbilicus, the intestines 
rising there upon the fluid to the surface under the abdominal walls. 
Elsewhere, the sound is dull, even flat. 

The amount of fluid in ascites is sometimes immense ; as much as 
twenty-five pints have been withdrawn at once by tapping. It is 
generally clear, pale yellow or colorless, albuminous and alkaline. 

Ovarian Dropsy. — Leaving the history of this, as belonging to the 
special department of diseases of women, it is right to state that its 
diagnosis is important, but not always easy. Like ascites, it produces 
abdominal enlargement, with dulness on percussion and fluctuation. 
The most nearly constant points of distinction are, that the ovarian 
tumor begins somewhat on one side, and only by degrees becomes 
symmetrical ; its shape is, throughout, more globular and coherent, 
and altered less by changes of position ; and the intestines do not float 
up above the umbilicus so as to make a clearness of percussion-reso- 
nance there. The progress of ovarian dropsy is usually slower, and 
attended by less proportionate depression of the general health. 

Treatment of Dropsy. — Acute general dropsy, from suppression 
of the action of the skin and kidneys, should be treated by active 
purgation and the use of diuretics. Jalap and cream of tartar (gr. x. 
of the former with 31J to £iv of the latter) every day or two, will 



248 DROPSIES. 

answer well for catharsis. The diuretics most satisfactory are the 
infusion of juniper berries (a pint daily), acetate of potassa, citrate of 
potassa, squills, and sweet spirits of nitre [F. 37, 38, 39, 40]. When 
the patient is hard to purge, elaterium may be given, in gr. £ doses, 
every four hours till it operates. 

Ascites, or other dropsy, from disease of any of the great organs, 
kidneys, liver, or heart, being less curable, and attended by greater 
general debility, needs more economy of strength. No doubt exists 
that real harm may be done by the routine of severe purging and 
plying with diuretics. The one may render the blood thinner and 
aggravate the constitutional disease, while the others, failing to remove 
the fluid by secretion, may even irritate the kidneys to the point of 
suppression of their action. Nourishing concentrated food, tonics, 
anodynes, &c, may, in visceral dropsy, be of more importance than 
diuretics. Of course it is desirable to lessen the accumulation of 
fluid ; but the effects of the remedies used must be observed, and one 
symptom must not be allowed to overshadow the rest. 

When enormous distension makes rest impossible, and almost pre- 
vents breathing, it is necessary to relieve it by any possible means. 
Then, purging, as, by elaterium, should diuretics fail, must be resorted 
to. Or, if the patient's stomach or general strength will not bear 
that, paracentesis, tapping, is called for. Some patients require this 
many times. 

The operation is best performed while the patient is lying down, 
upon the side, near the edge of the bed. A trocar and canula are 
introduced half way between the pubes and the umbilicus, and the 
fluid is drawn out through the canula. Then a bandage (with a com- 
press) is applied firmly around the abdomen. Some practitioners 
favor keeping open the orifice, with a slip of lint, to maintain drainage. 
If no local irritation occur, threatening peritonitis, in consequence, 
this may be a serviceable measure. If the bolder practice of inject- 
ing iodine after tapping (as in hydrocele) should be thought of in any 
instance, it must be that of simple peritoneal dropsy, uncomplicated 
by serious visceral disease. 

Sometimes oedema of the lower limbs and scrotum becomes so great 
as to cause great inconvenience. Then the fluid may be let out by 
making a number of small punctures with an abscess lancet or small 
pointed bistoury. The only drawback to this is the possibility of 
erysipelatous inflammation about the punctures. Such danger will 
not be at all great if, immediately after the operation, the parts be 
soothed by bathing or anointing the skin with diluted glycerin (f^j 
in fgj of rosewater), or cold cream (ung. aq. ros.), or glyceramyl (gly- 
cerin and starch) [F. 148]. 

For the treatment of ovarian dropsy, the reader is referred to works 
upon surgery. I only venture the opinion, that the place of ovario- 
tomy has hardly yet been defined clearly and with certainty by experi- 
ence. If compelled to decide upon it in a doubtful case, I should 
incline towards the views of those who make it a very rare operation. 



VARIOLA. 249 

ZYMOTIC DISEASES. 

VARIOLA. 

Synonym. — Smallpox. Varieties. — Discrete and confluent ; also, 
varioloid or modified smallpox, after vaccination. 

Symptoms and Course. — Stages : These are, incubation, primary 
fever, eruption, secondary fever, and desquamation. The incubation 
(period between exposure to the contagion and beginning of the 
attack) lasts about twelve days. The first symptoms are languor, 
headache, vomiting, and severe pain in the back ; soon developing 
into fever. On the third day of this, pimples, at first small and red, 
appear, first on the face, then on the neck, arms, trunk and lower 
limbs. These papules become vesicles and then pustules ; suppurat- 
ing perfectly by the ninth day of the fever. Then they flatten and 
scab. Four or five days later, about the fourteenth day of the fever, 
these scabs begin to fall off*. Desquamation is commonly completed 
by the end of the third week of the attack. To recapitulate; there 
are, after about twelve days of incubation, three of primary fever, six 
or seven for the coming out and maturing of the eruption, four or five 
for its scabbing, and six or seven for desquamation. 

These periods vary somewhat ; and the severity of the disease de- 
pends mostly upon the amount of the eruption. This makes the dif- 
ference been the discrete (scattered, separate) and confluent smallpox. 
Even the primary symptoms are generally worse in the latter. The 
secondary fever, connected with the full development of the eruption 
(about the eleventh day of disease), is much the most severe in the 
confluent. The suffering of the patient is great, even extreme, in this 
form, the whole surface of the body being covered with inflamed pus- 
tules. Even the eyes, mouth, and throat may be invaded. Blindness 
sometimes follows ; and I knew of one case in which the eruption in 
the throat proved fatal by obstruction of the breathing and swallow- 
ing. A peculiar and disagreeable odor emanates from the body in 
confluent cases. 

Malignant smallpox is simply a violent form of it characterized 
by rapidity, and extreme prostration, with or without extensive pus- 
tulation. The eruption, in it, is sometimes attended by lividity of the 
skin. Delirium is common, and a typhoid stupor may exist. 

After smallpox, abscesses in various parts of the body, hard glan- 
dular enlargements, ulceration of the cornea, suppuration of the ear, 
pneumonia, or pyaemia may occur. 

The danger to life in this disease is always serious. Before vacci- 
nation, thousands died annually from smallpox. 

Causation. — There is no disease more certainly contagious than 
variola. Generally either contact or approach within a few feet 
seems necessary for its conveyance ; but I have met with one instance 
in which it must have traversed the high walls of an inclosed public 
institution, attacking an inmate who had not left the house for ten 
years, and without the admission of any one who could have brought 
it. In the large majority of cases, smallpox occurs but once in a life- 



250 ZYMOTIC DISEASES. 

time. Exceptions are well known, however ; some in which the same 
person has had it three, — it is said, even five times. 

Treatment. — The preliminary symptoms of smallpox do not differ 
from those of most other acute disorders, except that the headache, 
pain in the back, and vomiting are apt to be more severe. In that 
stage, rest in bed, after a warm mustard foot-bath, and drinking hot 
lemonade to promote full reaction, will be enough to do. The fever 
calls, first, for a cooling laxative dose, as Rochelle salt or citrate of 
magnesia. Then, refrigerant diaphoretics will be in place ; as neutral 
mixture [F. 149, 150], effervescing draughts, or liquor ammonias 
acetatis ; the first if the stomach be good and the bowels slow to act; 
the second if nausea or vomiting continues ; the third if the bowels 
are free and the fever low in type. No cutting short of smallpox is 
possible; it is a self-limited disease. There is no specific remedy for 
it ; we can palliate it only, and conduct the patient through it. 

So decided is the tendency to exhaustion of the system in severe 
smallpox, that early support by concentrated liquid nourishment must 
be the general rule. As in other acute illness, appetite and digestive 
power are almost lost. Milk, however, in small quantities often (one 
or two tablespoonfuls every two or three hours) and chicken or mutton 
broth, or beef-tea may be given. Other sick diet, as gruel, arrowroot, 
toast-water, &c, may do during the primary fever. But a good many 
cases will require even wine-whey or brandy punch in the second and 
third weeks ; malignant cases, perhaps, in the first. Quinine should 
go with these, in tonic doses ; e. g., one or two grains every three or 
four hours. An opiate at night is often serviceable, especially in the 
confluent form. Sarracenia purpurea is of no use whatever in small- 
pox. 

An important object often is, to prevent the pitting of the face. 
Three plans are resorted to: 1. To abort the vesicles. 2. To soothe 
and mitigate the inflammation connected with them. 3. To exclude 
air and light during the scabbing and desquamation. The first of 
these ends is sought by touching each pimple, on the face, on the 
fourth or fifth day of the attack, with a point of lunar caustic. Sooth- 
ing inflammation is aimed at by covering the whole face during the 
first week with a soft poultice of bread and milk, flaxseed meal, or 
slippery elm bark. Exclusion of the light may be attained by gold 
leaf; of air, by mercurial ointment, or collodion, softened by adding 
7 \jth part of glycerin before it is painted upon the face. 

How are we to choose ? I would begin by touching the worst 
papules, on their second day, with nitrate of silver. Then poultice the 
whole face for four or five days, till the pustules flatten and umbilicate. 
Lastly, apply the collodion, softened by the addition of glycerin, with 
a camel's hair pencil, over each pustule, thickly enough to make an 
artificial cuticle ; which may be renewed, every day or two, until des- 
quamation has been completed. 

The sequelce of smallpox must be treated as they arise, by the open- 
ing of abscesses, improving the tone of the system by iron, &c Great 
care is needed in convalescence from this, as from other acute (especi- 
ally eruptive) diseases, not to be exposed to sudden changes or ex- 
tremes of temperature. The danger of pneumonia, pleurisy, or bron- 
chitis is, at such times, much greater than usual. 






VACCINATION. 251 

Varioloid : Modified Smallpox. — In those who have been vaccin- 
ated, while the liability to be affected by the virus of smallpox is in 
most cases removed, in a few the disease is taken, on exposure, in a 
milder former. The primary fever is rather less severe, the eruption 
is more scattered, the pustules are not so deep nor so much inflamed, 
they scab sooner, and very rarely pit ; and there is no secondary 
fever. Varioloid is seldom fatal. Its treatment should be essentially 
the same as that of smallpox ; only there is less often need of special 
measures to prevent marking of the face. 

VACCINATION. 

The ancient practice of inoculation 1 with smallpox, while it was, by 
the mildness of the attack, nearly always protective of the individual, 
at the same time propagated the disease, multiplying the amount of 
its virus. Jenner's introduction into professional practice of inocula- 
tion with the virus of cow-pox, known before his time among dairy- 
men, has greatly abridged not only the destructiveness, but the preva- 
lence of variola. 

Whether " vaccinia" or cow-pox is smallpox affecting the cow, or 
is a different disease whose virus is protective, against smallpox, is not 
yet determined to the satisfaction of all investigators. i Experiments 
have been tried repeatedly, with conflicting results. Either way, the 
fact is plain, that most persons are, by one good vaccination, pro- 
tected for life ; that modified smallpox, occurring in the vaccinated, 
is very seldom indeed fatal, and hardly ever pits ; and that repeated 
vaccination, after an interval of years, will make protection almost 
always complete. 

Vaccination may be performed either with the fresh lymph, the 
same dried by keeping, or the scab; and, either directly from the 
udder of the cow, or from a human being inoculated with cow-pox. 
In Europe the lymph of the vesicle, before maturation, is generally 
preferred. In this country the scab is used, and is found reliable, 
when fresh enough. No matter how it is kept, after a month it is 
uncertain ; although it has sometimes been found efficient after being 
sealed up for a year. 3 

Direct inoculation from the cow makes a very sore arm, with con- 
siderable fever. For infants, unless rugged in health, this is an un- 
desirably severe process. It is. at the same time, probable that many 
transits through human bodies may somewhat modify the virus. 

1 Inoculation was introduced into England from the East by Lady Mary 
Wortley Montagu, in 1718. Dr. Boylston, of Boston, brought it into practice 
in this country in 1721. Dr. Jenner's first vaccination was performed in 1796. 
Vaccination was first performed in America in 1799 j in France, in 1800. 

2 Dr. Cutter, of Boston, inoculated 50 cattle with virus of smallpox, without 
producing any definite pustule. He then vaccinated the same cattle with cow- 
pock virus ; they all took it regularly. This looks as if vaccinia is a distinct 
disease peculiar to the cow ; but other facts are opposed to these. 

3 Recent observation, authentically reported, seems to show that glycerin 
will preserve vaccine virus for several months. The method used in England 
is, to take matter from the sore on the eighth day of the vaccination, on quill 
points, and mix it with ten times its bulk of glycerin diluted with an equal 
quantity of water. 



252 ZYMOTIC DISEASES. 

Kenewal, by inoculating healthy children, not too young, every now 
and then, from the udder of the cow, is to be recommended. Cattle 
with the cow-pox may be found in almost any agricultural neighbor- 
hood. 

In the absence of smallpox, the second month of infancy will be 
time enough for vaccination. But under danger of exposure, a babe 
should be vaccinated at any time after birth. Matter only from 
healthy children ought ever to be used. While it is unlikely that any 
constitutional disease (as syphilis' or scrofula) can be so introduced, 
there should, in practice, be no room left for any doubt of the kind ; 
and some cutaneous diseases might certainly be transmitted. Unless 
on account of risk from exposure, the existence of an eruption on the 
skin, or any other indisposition of the child itself, may be a reason for 
postponing the operation. The excitement produced by it may 
aggravate an existing inflammatory affection. Yaccination has often 
been blamed for the breaking out of eruptions, supposed to be trans- 
mitted, when their cause was really the state of system of the patient. 

For the operation, the outside of the arm, near the shoulder, is 
commonly selected. The exact method used is not important. A 
small, wedge-shaped lancet, or even a sharp-pointed penknife, will do. 
Yarious slides have been contrived for the purpose. I prefer to cut 
or push out a very small flap of cuticle, under which a thick paste 
made by pressing and mixing a portion of the scab with a drop of 
tepid water may be inserted. The art of the operation is, to pierce 
the skin without drawing enough blood to flow ; it is most successful 
when there is no blood at all. Besides the flap, it is as well to scratch 
the skin, and puncture it, at a little distance, giving three chances of 
taking instead of one. No disturbance of the arm must be allowed 
for twenty minutes or half an hour afterwards. 

If it be successful, no sign of it is distinctly visible for two or three 
days. On the fourth day a decided, small red pimple is to be seen 
and felt. This is a vesicle of some size on the fifth day ; it grows 
large and cylindrical, or hat-shaped, and by the tenth or eleventh day 
is fully umbilicated, or depressed like a navel in the centre. Before 
that, about the eighth day, the bright red ring or areola forms around 
it. This fades after the eleventh day, and the vesicle dries up into a 
round and flat, but rather thick, mahogany-colored scab, which falls 
off about the nineteenth day. All of these particulars are important, 
as showing the genuineness of the vaccination. So is the appearance 
of the cicatrix left ; which should be large in proportion to the vesicle, 
and dotted or marked with subdivisions. This is owing to the vesicle 
being composed of several small cells or compartments. 

Slight fever, with restlessness, is not unfrequently observed during 
the first few days after the vesicle appears ; but there is rarely any- 
thing requiring treatment. 

Re-vaccination. — Experience shows that a small number of per- 
sons, after several years, reacquire the susceptibility to smallpox. As 
the only test of this is exposure either to the latter or to vaccinia, 

1 At Rivalta, Italy, and Morbihan, in western France, a number of cases of 
syphilitic disease (primary and secondary), following impure vaccination, have 
been reported ; the last instances by H. Roger and Depaul. 



VARICELLA — SCARLATINA. 253 

the renewal of the latter, at least once after puberty, is always advisa- 
ble. On the occasion of epidemics of smallpox, it may be repeated 
again and again. There is no pain of any consequence in this 
operation, nor danger, and, if a genuine vesicle form, making a sore 
arm, that discomfort for a few days cheaply purchases immunity from 
the terrible disease. I have sometimes thought it possible that the 
system may be protectively affected by re-vaccination, even when no 
local effect, or only a " spurious" sore follows. Certainly smallpox is 
extremely rare in re-vaccinated persons. 

The virus from a second vaccination should not be relied upon 
for use. 

VARICELLA. 

Synonym. — Chicken-pox. This is a mild exanthematous disease 
resembling smallpox or varioloid considerably. After an incubation 
of four or five days from exposure to the contagion of one having it, 
pimples form, generally scattered widely. In the second day they 
become vesicles filled with lymph. Two or three days more find them 
scabbing ; they dry and fall off soon, without pitting, except in rare 
instances. There is little or no fever or other indisposition. The 
disease is attended with no danger to life, and requires only precaution- 
ary treatment, i. e. to avoid exposure to cold and wet, to keep the 
bowels regular, and, if needful, promote action of the skin by a 
diaphoretic, as neutral mixture. 

The eruption of varicella differs from that of variola in coming out 
in successive crops ; in not suppurating or becoming umbilicated ; and 
in not deeply involving the true skin. 

SCARLATINA. 

Synonym. — Scarlet fever. 

Varieties. — Scarlatina simplex, aiiginosa, and maligna. 

Symptoms and Course. — After an incubation supposed to be about 
five days after exposure to its cause, lassitude, anorexia, headache, 
and pains in the back and limbs mark the beginning of the attack. 
Soon these are followed by fever ; on the first day, very often, the throat 
is sore. On the second day, usually, a punctated red eruption appears 
on the face and neck, and in ten or twelve hours has covered the whole 
body. It is of a scarlet, or sometimes a brick-red hue, uniformly 
diffused, with a swollen appearance, and great heat ; reaching by the 
thermometer even 106° Fahr. Occasionally miliary vesicles are seen. 
There is also a sense of burning and some soreness or irritation of the 
skin. The tongue has a strawberry -like look, from the projection of 
enlarged red papillae through a whitish fur. I he throat is very red 
and swollen, generally, with a hue not unlike that of the skin. Fever 
runs very high, with an extremely rapid pulse, great thirst, headache, 
perhaps delirium, costiveness, in some cases vomiting. Bad cases 
may have stupor. By the fifth day, mild examples of the disease show 
, already an abatement. Most have passed the height of the pyrexia 
by the ninth ; although sequela? may protract the attack much longer. 
Malignant cases may be fatal in a day or two, or even in less than 
22 



254 ZYMOTIC DISEASES. 

twenty-four hours. Desquamation of the skin follows the fading of 
the eruption ; often large masses of cuticle coming away at once. At 
this stage more or less decided albuminuria is common. 

Scarlatina Simplex. — In this the eruption comes out early and 
well, with moderate fever, little inflammation of the throat, and an 
even course throughout. Sometimes there is hardly any febrile dis- 
turbance ; and the child may play about without having to go to bed. 

Scarlatina Anginosa. — Here the violence of the disease falls upon 
the throat chiefly. The tonsils swell greatly, suppurating either early 
or late, or they are covered by pseudo-membranous deposit, white, 
gray, or dark-brown, whose coming away leaves an ulcerous surface, 
with in some instances an acrid, offensive discharge. The extension 
of the ulcerative inflammation may pass the Eustachian tube to the 
tympanum, and even may destroy the auditory apparatus so as to cause 
permanent deafness. After the rash has disappeared, abscesses in 
the neck may form and discharge, exhausting the patient. 

Scarlatina Maligna. — This term designates an overwhelming 
toxemic impression of the morbid cause of the disease. Depression 
in the first stage becomes intense, without reaction ; or, after the 
eruption has partly come out, it recedes, or grows livid in appearance ; 
or the brain is oppressed with coma. Coldness is sometimes present, 
or unequal temperature of different parts of the body, instead of the 
usually diffused febrile heat. The throat may be much or little affected. 
In some instances the patient seems almost as if struck by lightning, 
— so sudden and deep is the general prostration. In this condition 
death may take place in a few hours. Otherwise, with continued 
prostration, hemorrhage from the stomach or bowels, or vomiting, or 
diarrhoea, threatens an untoward result. 

Sequelae. — Abscesses about the throat have been mentioned ; simi- 
lar local affections may take place elsewhere after the attack. Ozsena 
is not uncommon ; neither is suppurative inflammation of one or more 
of the joints, or of the testicle; nor vaginitis. Endocarditis or peri- 
carditis may occur. So may paralysis ; either hemiplegia or paraple- 
gia ; generally it is partial, and it is often slowly recovered from. 

Dropsy, from arrested action of the kidneys, with imperfect action 
of the skin, is the most common and in many cases the most serious 
of the sequelae of scarlatina. It comes most frequently within a week 
or two after desquamation has commenced. Mild cases are almost as 
likely to be followed by it as severe ones. Exposure to cold is the 
generally observable direct cause ; but cases happen in which no such 
exposure could have existed. Anasarca is the least dangerous though 
most frequent form of this dropsy. There may, instead or in addition, 
be ascites, hydrothorax, or hydrocephalus. Albuminuria, and often 
hematuria, accompanies either form. 

Diagnosis. — From measles scarlet fever is known by the eruption 
coming out on the second day, without catarrhal symptoms but with 
sore throat, — and by its being of a brighter red color, and uniformly 
diffused instead of being in patches. 

From roseola, it is distinguished by the fever and sore throat, and 
by the rash, in the latter, being in irregular blotches, damask rose 
color instead of the brick or scarlet-red hue. 

Prognosis. — This is proverbially uncertain in scarlet fever. The 



SCARLATINA. 255 

simple form is. however, the least dangerous, and a very large majority 
of cases get well. The anginose is more threatening and serious. 
But the malignant variety, as its name indicates, is far the most so : 
recovery from it is the exception, although it does occur. I have 
known two cases of such recovery: one. in which coma was complete 
for thirty-six hours. Adults are. when affected with scarlet fever, in 
somewhat greater danger than children ; and so. especially, are puer- 
peral women. 

Causation. — Although most (not all) authorities agree that this 
disease is contagions, it is certainly very capricious or variable in its 
manifestation of this quality. That is. many persons who are exposed 
escape it. It is true, that several children in a family often have it 
in immediate succession. But the escape of all but one is. so far as 
my observation has gone, as common. It rarely occurs twice in the same 
:u. I remember but one or two instances of this in my own practice. 

Treatment. — Mild cases require no medication at all. other than to 
make sure that the bowels are well opened. If fever is high, after a 
saline cathartic, as citrate or sulphate of magnesia, or Bochelle salts, 
neutral mixture or effervescing draught, or liquor of acetate of ammo- 
nia may be given. Sweet spirits of nitre may be added, in small dose 
(| to | fluidrachm for an adult, and proportionately less for a child) 
if the kidneys act slowly. Drinking cold water freely is to be en- 
couraged : as it is demanded by thirst. If the throat be much inflamed, 
the frequent melting in the mouth of ice, in small pieces, will do good. 

Venesection is prohibited now in scarlatina by nearly all writers. In 
the early part of my practice. I bled from the arm in six cases, all of 
which did remarkably well. They were examples of violent fever with 
severe sore throat and headache, in children of good constitution. I 
do not advocate the practice, simply in deference to the common 
opinion of the profession. Certainly it should be always ruled out in 
asthenic cases, and in all unless at the early stage of the fever. 

For the sore throat, which is specific in character, besides the use 
of leeches externally if the inflammation be great and the case sthenic, 
local alteratives may be used. An old and popular gargle is one of 
red pepper, vinegar, and water. More powerful in changing the cha- 
racter of the inflammation. I think, is a strong solution of nitrate of 
silver (gr. xxx in fgj) applied with a large hair pencil. TThen pseudo- 
membranous patches appear, with a tendency to fetor or ulceration, 
muriatic acid, with honey, equal parts, may be applied in a similar 
way : or. diluted, used as a gargle. Sulphate of zinc [gr. xv to xx in 
f§j is also a good application: and so are solutions of creasote in 
glycerin: chlorinated soda: and permangauate of potassa. 

For the irritation of the skin connected with the rash, according to 
my experience the best relief is to be obtained from sponging with 
cool or tepid water, two or three times a day. Inunction with lard, 
or glycerin, is preferred by some. Cold arfusion is unnecessarily vio- 
lent and troublesome. 

The diet in scarlet fever should be. as a rule, liquid, but need not be 

generally, in the sense of dilution or exclusion of animal material. 

unless in the first few days. Sooner than in most diseases, the tendency 

to debility is manifest. Then. milk, chicken bruth. mutton tea or beef- 

tea. .v.;-.. will be suitable. At the same stage, some patients will re- 



256 ZYMOTIC DISEASES. 

quire a tonic treatment, by quinine, or, as some prefer, nitric acid in 
small doses. 

Malignant scarlatina is a disease of terrible depression from the 
outset. Deficient reaction is one of its characteristics. To promote 
this, external stimulation is primarily important. The hot salt or 
mustard bath is a powerful agent for the purpose. Urtication, i. e., 
the direct application of fresh nettles, has been sometimes employed. 
Mustard plasters may be applied energetically ; and so may hot bottles, 
or bags of hot salt, &c. internally, ammonia, quinine, and capsicum 
are the most prompt and reliable stimulants, although we may add to 
the same list, Hoffmann's anodyne, and brandy, whisky, or wine. Where 
a tendency to stupor exists, free purging will be the main hope. Jalap 
is a convenient article for the purpose [F. 151]. 

The sulphite of soda is now, very reasonably, under trial in various 
zymotic diseases, as an antagonistic of morbid blood-changes. The 
dose for an adult (perhaps not yet well settled) may be about ten 
grains every two or three hours [F. 152].- Chlorine water, in flui- 
drachm doses for an adult (ten drops for a child of two years) is some- 
times given in scarlet fever with a similar view ; and so is chlorate of 
potassa. 

Other modes of treatment for severe cases are, the use of tincture 
of chloride of iron freely ; of infusion of digitalis ; of diluted acetic 
acid (gj to £iv of the officinal acid in f^iv of water, the dose of the 
solution being a tablespoonful, sweetened, every few hours) ; and of 
diluted nitric acid. 

Of the sequelce of scarlet fever, each has its own indications for 
treatment. That of dropsy is the most frequently important. If, 
during desquamation, the kidneys show any threatening of inaction or 
suppression, the greatest care of the state of the skin must be main- 
tained. It is, indeed, a good rule of precaution, for fear of some care- 
lessness or exposure, not to allow a patient recovering from scarlet 
fever to leave his chamber for three or four weeks at least from the 
beginning of the attack, nor the house for four or five. Lemonade as 
a drink, if the urine be scanty, may be freely used. Cream of tartar 
and acetate of potassa are approved in the same case as diuretics. 
Digitalis has the confidence of many. Quinine,'m doses large enough 
to cinchonize, is reported very favorably of, in scarlatinal dropsy, by 
some practitioners. Dry cupping to the lumbar region, and the appli- 
cation there of a large mustard plaster, are measures suggested by the 
known congested state of the kidneys. Purgatives must not be omitted 
when diuretics fail ; the principles governing their use being the same 
as in other varieties of dropsy. 

Prophylaxis. — Belladonna has been asserted to have a protective 
power against the contagion or infection of scarlet fever. But the 
evidence in its favor does not appear to me to warrant our giving any 
confidence to it, or to any prophylactic. 

MEASLES. 

Synonym. — Moroilli. Formerly, with all writers, and still with 
many, rubeola is a synonym for measles. Some English writers, how- 
ever, designate by the name of rubeola only a hybrid or blending of 
measles with scarlatina. 



HYBRID BETWEEN SCARLATINA AND MEASLES. 257 

Symptoms and Course.— After an incubation of from ten to fifteen 
days from exposure to its contagion, measles begins with aslight or 
obscure stage of depression, passing into fever. With this there are 
all the symptoms of a cold ; running at the nose, redness and watering 
of the eyes, and a cough. On the fourth day of the attack the rash 
begins on the face, and extends over the body and limbs. It is not so 
bright in color as the eruption of scarlet fever ; and is irregularly 
distributed in patches, more or less crescentic in shape. By about 
the seventh day the rash begins to fade, and about the same time or 
before, the fever has begun to decline. Desquamation is much less 
extensive than after scarlatina. 

No such intensity of febrile movement, nor severity of any kind, as 
is common in the last named disease, exists, except very rarely, in 
measles. Camp measles, during the late war in this country, often 
assumed a typhous character, with a considerable mortality ; due to 
the conditions under which it occurred among the soldiers. Other- 
wise measles seldom threatens life. 

The sequelae which are of the most consequence are, ophthalmia, 
diphtheria, chronic bronchitis, and phthisis. Very severe inflamma- 
tion of the eyes sometimes follows measles ; but blindness from this 
cause is rare. Diphtheritic sore throat is not infrequent, and may be 
fatal in children. Chronic bronchitis is common, especially when care 
is not taken during convalescence to avoid exposure. Phthisis, under 
the same circumstances, is to be apprehended only where the consti- 
tution suffers under a predisposition to tubercular disease. 

Causation. — Measles is one of the most contagious of diseases, be- 
yond all doubt. Singularly enough, however, I once attended with it 
one of a pair of twins at the same mother's breast, the other escaping 
it altogether. A second attack is exceptional, but not very rare. 1 

Treatment. — Beginning with a moderately active saline cathartic, 
diaphoretics, expectorants, and demulcents are next in place. Syrup 
of ipecacuanha with neutral mixture (| drachm of the former, for an 
adult with each tablespoonful of the latter) every two, three, or four 
hours, would be an average treatment for the first week ; flaxseed 
lemonade being freely used as a drink. After that, the continuance 
or relief of the bronchial symptoms must determine whether some 
other expectorant (as squills or wild cherry) shall follow. Or, de- 
bility may require tonics during convalescence. 

HYBRID BETWEEN SCARLATINA AND MEASLES. 

This, called Rubeola by some, is not common, but undoubtedly does 
occur. I have seen a case in which the symptoms of the two disorders 
were so nicely balanced that two physicians of similar experience 
pronounced it, the one scarlet fever, and the other measles. In 
severity it is more like measles ; although dropsy and albuminuria may 

1 Not long since, Dr. Salisbury of Ohio produced measles-like symptoms 
in several persons by exposing them to the influence of fungi growing upon 
damp straw. The identity of the affection with measles is not, however, 
certain. Drs. Hammond and Woodward, at Washington, repeated the same 
experiments without result. 

22* 



258 ZYMOTIC DISEASES. 

follow it, as well as bronchitis, &c. Its treatment requires no special 
consideration, being involved in what has been said of the two dis- 
eases of which it really seems to be a combination. 

MUMPS. 

Synonyms. — Parotitis contagiosa ; Cynanche parotidea. 

Symptoms and Course. — This is generally a mild affection, of a few 
days' duration. The parotid gland swells and becomes hot, painful, 
and tender to the touch. Some inconvenience in swallowing may 
result. There is little or no fever, but some general malaise ; and the 
attack is generally at an end within a week. One or both parotids 
may be affected. There seems to be reason to believe that attacks 
may occur at considerable intervals, even of years, involving first one 
gland and afterwards the other. Suppuration is rare ; I have seen it 
but in one case. Mumps is undoubtedly contagious. 

Diagnosis. — As the parotid gland, as well as other glands about 
the neck, may inflame from cold, salivation, or scrofula, it becomes 
sometimes a question whether a swelling in that region be mumps or 
not. When the parotid alone is affected, it is impossible to decide, 
unless immediate exposure to another case of mumps be known. The 
parotid is, however, not apt to inflame under other causation, even 
from salivation by mercury ; the submaxillary glands are much more 
liable to swell from that cause. The suddenness of the attack, and 
its brief duration are generally also quite diagnostic of mumps, as 
compared with scrofulous or other inflammations of glands about the 
neck. 

Complications. — Metastasis of mumps, to the mamma or testicle, 
or, it is asserted by good authority, even to the brain, occasionally 
occurs. In either of the first two, a somewhat similar inflammation 
of the gland attacked takes place ; usually more protracted than that 
of the parotid. If the brain be the seat of the transfer of the morbid 
element or action, meningitis, or coma, may follow ; and even death 
is said thus to have resulted. I have never met with any case of the 
kind. Otherwise, mumps are free from danger to life. 

Treatment. — Care to avoid being chilled, lest metastasis or greater 
severity of the attack be produced, is important. No general treat- 
ment is necessary, nor does the patient usually need to remain in 
bed. Perhaps a mild laxative may be given on the first or second 
day. A poultice of flaxseed meal is a good local application for the 
gland. It may also be bathed night and morning with soap or volatile 
liniment. 

HOOPING-COUGH. 

Synonym. — Pertussis. 

Symptoms and Course. — After an incubation of about six days, 
with symptoms much like those of acute bronchitis, including fever 
of variable degree, the attack commences ; soon showing its peculiar 
character. This is, a spasmodic and paroxysmal cough. For hours, 
the patient may be apparently well ; and then, often with a premoni- 
tory sensation which leads the child to run to its mother or nurse, or, 



HOOPING COUGH- 259 

if at night, to sit up in bed, a fit of coughing begins, and lasts for 
several seconds or minutes. It consists of a rapid succession of short 
but violent expiratory efforts, with scarcely any intervals of inspira- 
tion ; at the close of which air is taken in by force through the con- 
tracted glottis, making a whooping sound, whence the name of the 
disease. All who have it do not whoop ; but the paroxysmal charac- 
ter of the cough is pathognomonic. 

Expectoration is often copious, of thick mucus, sometimes even of 
lymph and pus. Vomiting occurs very often, during the spells of 
coughing. The child may become very much exhausted, even to a 
fatal end; but unless from complication or previously feeble constitu- 
tion, death does not very often occur. I never knew asphyxia to be 
fatal during the paroxysm ; though it is sometimes very threatening. 
There may be many variations of severity in all the symptoms in the 
course of an attack. 

The duration of hooping-cough is seldom less than six weeks, 
although cases have ended within three weeks. Often it lingers for 
three or four months ; in one case I knew it to last a year. 

Complications. — Pneumonia, collapse of the lungs, and (as a 
sequela) phthisis, are the most liable to occur. Deafness from rap- 
ture of the membrana tympani during the violent coughing, has been 
known. Sometimes the eyes become blood-shot from the same cause. 
Convulsions occasionally increase greatly the seriousness of the dis- 
order. 

Causation and Pathology. — There is no question of the conta- 
giousness of hooping-cough. Generally it occurs but once in the 
same person ; but second attacks are not very rare. Like scarlet 
fever, measles, &c., it is much most often met with in children; but 
this is merely from their susceptibility under exposure ; as adults also 
have it. 

Belonging with the zymotic diseases, caused by a specific morbid 
poison, the spasmodic nature of the cough points to the nervous 
system as in main part the seat of its action. Yet the expectoration 
as well as early (and occasional, afterwards) febrile symptoms, show 
that bronchial inflammation exists, secondarily at least. 

Treatment. — Mild cases need only care to avoid exposure to damp 
and cold. After the first few days, if there be no fever nor soreness 
of the chest, the patient need not be kept in the house in good 
weather. Indeed, he will cough least when most out of doors. 
"When the cough, at first, is tight and painful, with little expectora- 
tion, syrup of ipecac, or squills, may be given. As soon as the 
spasmodic character of the cough declares itself, with some violence, 
the " milk," or the tincture, of assafcetida may be given ; with or with- 
out other expectorants according to the case [F. 153J. Severe cases 
may be quieted by belladonna or musk ; but I have been especially 
satisfied with the effect of the fluid extract of hyoscyamus, in the 
dose of from four drops in a child of ten or twelve years of age, down 
to a fraction of a drop at a time, in a young infant [F. 154, 155, 156]. 
Hydrocyanic acid, bromide of ammonium (from two to twelve grains 
at once for a child), nitric acid, alum, clover-tea, and benzoic acid are 
among the other remedies often employed to allay the violence of the 



260 ZYMOTIC DISEASES. 

paroxysms. Application of strong solution of nitrate of silver to the 
larynx has some advocates. 

In protracted cases, counter-irritation to the chest and back of the 
neck may be required. I once met with great relief upon the appli- 
cation of a small blister to the nucha. Tonics are also not unfre- 
quently called for toward the end of the attack in a feeble child ; 
especially quinine, or tincture of bark (Huxham's), iron, or cod-liver 
oil. There is very seldom need to restrict the diet in this disease, 
unless during the first week. 

DIPHTHERIA. 

Synonyms. — Pseudo-membranous Angina ; Putrid Sore Throat; 
Diphthentis. 

History. — Though the name diphtheria (from 8i$9epa, a skin or 
membrane) was only given to this disease by Bretonneau of Tours 
about forty years ago, it appears to have been described by Aretaeus 
of Cappadocia as a disease of Egypt ; and was mentioned also by 
Macrobius and Ccelius Aurelianus among early writers. Hecker gives 
account of its prevalence in Holland in 1337; Carnevale, at Naples, 
1620 ; Tamayo, at Madrid, called it garotillo, in 1622. Ghisi first 
clearly described the pseudo-membranous formation, at Cremona, 
1740. In France, Ohomel saw it in 1743-9 ; in England, Fothergill, 
in 1754; Douglas of Boston, in this country, in 1736, and Samuel 
Bard of New York in 1771. Huxham, Oheyne, Eosen, Albers, and 
Gruersent also described it under different titles. Bretonneau most 
fully made it out as a distinctive disease, in 1826. Since that time it 
has been recognized and treated of by nearly all medical authorities. 

Late epidemics of it have been, principally, those of Paris and 
Boulogne of 1855-7, passing to England in the latter year ; and of our 
own country beginning in California in 1856, and in the Eastern States 
a little later, gradually increasing in prevalence until 1860. Since 
that time it has declined in frequency, although still existing, and 
sometimes attended by great local fatality. Bretonneau, not un- 
reasonably, supposes Washington and the Empress Josephine to have 
died of diphtheria. Stephanie, the beautiful queen of Portugal, and 
Yalleix, the eminent French physician, were victims of it. 

Varieties. — 1. Simple ; 2. Croupous ; 3. Ulcerative ; 4. Malignant 
diphtheria. 

Symptoms. — Premonitory, but not distinctive, are general malaise, 
slight sore throat, and swelling of the lymphatic glands behind the 
jaw. Then, in the simple form, fever occurs ; with headache, furred 
tongue, constipation, and difficulty of swallowing. On examination, 
a swollen and very red or purple appearance of the fauces will be 
observed, as well as of the palate and tonsils. Over one or both of 
the latter, there may be seen, often as early as the second or third day, 
a whitish or yellowish white membranous deposit. All the symptoms 
continue, in this form, from five to nine days ; when, in favorable 
cases, convalescence follows. 

The croupous form has caused the greatest number of deaths, 
especially in children. This seems especially prone to follow measles 
or scarlatina. In it, after the same early symptoms as those above 



DIPHTHERIA. 261 

described, but sometimes violent from the beginning 1 , increase of dis- 
comfort in the throat is complained of. Then an abundant yellow or 
brownish leathery exudation is found to cover the tonsils and fauces ; 
which, under the exudation, are much swollen. Often quite early in 
the attack, the pseudo-membranous intiammation extends to the 
larynx. This is shown by the usual symptoms of croup : the barking 
cough and voice, and difficult inspiration, becoming whistling or sibil- 
ant when the obstruction to breathing is the greatest. A fatal 
termination may occur, by asphyxia, in a very few days. This can 
only be averted by the detachment and expulsion of the membrane, 
without its re-formation. 

The ulcerative variety is not common. TThen destruction of the 
palate and tonsils has attended it. with copious dark-colored and 
pulpy exudation, and some extravasation of blood, it has been mis- 
taken for, and described as. gangrene ; whence the old name. " putrid 
sore throat." The occasional existence of true gangrene cannot be 
altogether denied. 

Malignant Diphtheria. — At the commencement of this, there is. 
with intense headache, not unfrequently vomiting, which is uncommon 
in the milder varieties, and hemorrhage from the nose, mouth, stomach, 
or rectum. Great dysphagia soon exists, and enormous engorgement 
of the submaxillary, parotid, and cervical glands. The tonsils, 
pharynx, and palate are covered thickly with a leathery deposit, at 
first yellowish, but soon becoming ash-colored, brown, or almost black, 
and of an offensive odor. The tonsils may suppurate or even slough. 
The nostrils are also sometimes involved ; being swollen, lined with 
false membrane, and emitting an acrid and fetid discharge. Ex- 
treme prostration comes on, at a more or less early period; it may 
be from the first day. The pulse becomes very rapid, the face lividly 
pale, morbid heat of the skin being followed by clammy coldness. 
Coma often precedes death. The latter may take place in three, four, 
or five, occasionally in one or two days ; sometimes from the constitu- 
tional impression of the disorder, before the local affection has been 
fully developed. 

Special Symptoms and Complications.— Albuminuria is present 
in most severe cases of diphtheria, from an early time in the attack. 
A diphtheritic affection of the skin has been now and then observed. 
A blistered or otherwise abraded surface will usually, in the course of 
the disease, be covered by false membrane. Pneumonia is an occa- 
sional and dangerous complication. 

Sequelae. — These are, especially, long-continued debility, paralysis 
of the soft palate, and general paralysis in various degrees. In the 
last of these, deglutition, articulation, vision, and locomotion may be 
involved. A fatal result may occur after a few weeks, or recovery 
after a longer period ; sometimes from two to eight months. 

Morbid Anatomy. — The pellicle or deposit, formed upon the highly 
injected and tumefied mucous membrane of the fauces and throat, 
constitutes the anatomical peculiarity of the disease. Minutely exam- 
ined, the false membrane is found to vary from ^ to £ of an inch in 
thickness, and to be fibro-laminated ; i. e., of layers of fibrinous net- 
work, including epithelial cells, and having on its free surface exuda- 
tion corpuscles or u pyoid globules." and granules; these forms 



262 ZYMOTIC DISEASES. 

appearing to be only stages of degeneration. No process of organiza- 
tion or development occurs in the mass ; it is aplastic. In some cases 
only a granular superficial infiltration of the mucous membrane is 
observed, without even distinct fibrillation. 

The common deposit of diphtheria differs from the false membrane 
of simple inflammatory croup, and still more from the " coagulable 
lymph" of inflamed serous membranes, in being thicker, more tough, 
yellower, and less capable of anything like organization. 1 (Dr. B. 
Sanderson asserts that he discovered evidence of development of the 
exudation in one or two specimens of the simple form of diphtheria.) 

Pathology. — Excluding from the title of diphtheria all instances of 
accidental or merely inflammatory " diphtheritic" or pseudo-mem- 
branous formations, as they occur, for example, in croup and scarlet 
fever, we must admit that there is a special zymotic or " enthetic" 
disease, for which that name is appropriate, and should be reserved. 
It is a toxsemic or "dyserasial" affection, in which the morbid change 
in the blood has its main and characteristic local manifestations in the 
throat. 

Causation. — Not doubting the existence of a special material cause, 
yet unknown except by its effects, we can only say further that the 
disease is generally epidemic or endemic, with a special tendency to 
limited localization. It acts with intensity in confined centres ; as, 
a small village, a crowded school, a numerous family ; inflicting therein 
often a terrible loss in proportion to the members attacked ; a sort of 
domestic pestilence. 

Is diphtheria transmitted by contagion ? I incline to believe that it 
sometimes is so, although clearly not dependent upon that mode of 
propagation in its epidemic migrations. The certain examples of its 
extending from one person to another are few ; but I think I have 
known of one at least. 

Children are much more liable to diphtheria than adults. Climate 
and season do not seem to affect its prevalence. Nor does it show 
any very decided preference for otherwise unhealthy places, where 
filth or crowd-poison abounds. Even its promotive causation, then, 
seems to be at present less known than that of most other diseases. 

Diagnosis. — From scarlatina, diphtheria is distinguished by the 
absence of the eruption, and of the peculiar punctated or brick-dust 
like flush of the throat, and "strawberry" tongue. That scarlet fever 
predisposes to diphtheria, as a subsequent attack, is a well established 
and not unimportant fact. 

With membranous croup, it is contrasted in the following manner. 
That disease is a sporadic and sthenic local phlegmasia, whose general 
symptoms are, as much as in any inflammation, dependent upon the 
local affection : while diphtheria is a constitutional disorder, usually 
epidemic, in which the local symptoms are secondary. More directly, 
in practice, we may mark the commencement of the pseudo-membran- 
ous deposit, in diphtheria, about the tonsils and pharynx; in croup, 
in the trachea or larynx. That of diphtheria rarely extends, in any 

1 Bretonneau long since, and Dr. Sanderson a few years ago, imitated the 
diphtheritic exudation, by injecting oil of cantharides into the throats of ani- 
mals. The principal difference was in the manifest tendency to organization 
in the cantharidal pseudo- membrane 



DIPHTHERIA. 263 

case, below the larynx ; that of croup, not unfrequently even into the 
bronchial tubes. After the laryngeal complication or extension has 
occurred in diphtheria, the croupal symptoms are really the same as 
those of any other laryngeal obstruction, and thus are not different 
from those of croup. 

From thrush, and aphthce, diphtheria is known by the deposit being 

much larger and thicker, never vesicular, and mostly duller in color; 

and attended generally by more severe constitutional symptoms. 

Thrush begins in the mouth ; it is, moreover, much more uncommon 

•in adults than diphtheria; and is never epidemic. 

Prognosis. — Simple diphtheria is not very dangerous to life. The 
croupal form is decidedly so ; and the malignant is fatal in a large 
majority of cases. Insidiousness is a trait often belonging to the 
disease in children ; a name which has been applied by some, for that 
reason, is "creeping croup." 

Treatment. — No specific remedy having been discovered for this 
disease, we must be governed in our tentative treatment of it by our 
idea of its nature ; while concluding upon its therapeutics, finally, 
through experience. Nothing, it may be confessed, is very satisfac- 
tory, as yet, in the management of bad cases of it. All agree that it 
is not a mere local inflammation, but a systemic affeclion primarily; 
and that its type is most generally asthenic. Much depletion is there- 
fore not to be thought of. I would never bleed from the arm in diph- 
theria. In simple, open cases, I have used leeches to the throat, with 
seeming decided advantage, within the first three days. Even their 
use, however, must be exceptional. Moderate purgation, as with 
citrate of magnesia, or Rochelle salt, at the very beginning, is well in 
the simple and croupal, though not in the malignant form. 

Chlorate of potassa is a favorite medicine with many in this disease. 
My best results in bad cases have attended its early and free use. An 
adult may take twenty grains in solution every three hours ; I have 
given five grains every two hours to a child five or six years old 
[F. 156]. 

Tincture of chloride of iron is relied upon by some ; from ten to 
twenty drops every three hours for an adult ; with or without the 
chlorate of potassa [F. 157]. Sulphate of quinine is also given, 
alone, or at the same time with the above remedies ; by a number of 
practitioners ; say, of quinine, for an adult, a grain every two or three 
hours. 

Besides these, or instead of them, for internal use, permanganate of 
potassa has, after some trial, the recommendation of one or two ob- 
servers. A drachm of it may be dissolved in a pint and a half of 
water, a fluidrachm of this being taken every hour. Sulphite of 
soda, ten grains every two or three hours, is worthy of trial in this, as 
in other zymotic diseases. 

Concentrated liquid food must, as a rule, be given throughout an 
attack of diphtheria ; milk, beef-tea, and very often wine whey or 
brandy or whisky punch ; in small quantities at short intervals, accord- 
ing to the degree of prostration present. 

Local treatment is, by most physicians, regarded as very important. 
Experience has shown, I think, that it ought not to be violent. Ice 
in smail pieces melted in the mouth slowly, is probably as usefu 



264 ZYMOTIC DISEASES. 

as any application. Muriatic acid and honey, equal parts, applied 
freely with a large camel's hair pencil ; or diluted with water and used 
as a gargle, 1 believe to be serviceable. Creasote dissolved in 
glycerin [F. 158] ; lime-water ; chlorinated soda dissolved in twenty 
parts of water ; and permanganate of potassa, a drachm in a pint, 
make also appropriate gargles. In a young child ice is often the only 
local application possible without a struggle so disturbing as to make 
the benefit of it doubtful. Cold water compresses may be applied 
outside of the throat in the early stage, while there is excess of heat. 
Later, flannel wrung out of hot water to which an equal amount of 
spirits or vinegar has been added, will give more comfort. 

Inhalation of the steam of lime-water is worthy of trial in diphtheria, 
especially in the croupous variety ; or, the atomization of lime-water 
by the nephogene or some other apparatus constructed for the pur- 
pose. 

But, I believe the local treatment to be, after all, secondary. And 
especially is the effort (which I have seen practised) to remove the 
patches of exudation by force, as by excision or actual cauterization, 
to be deprecated, as likely to do harm rather than good. 

GLANDERS. 

Synonym. — Equinia. Though not common in the human subject, 
it is important to know that this affection can be taken from the horse. 
It is said to occur either in the acute or the chronic form ; generally 
the former. 

Symptoms and Course. — After an incubation of from two to seven 
days, with febrile symptoms, the nostrils become inflamed, and at the 
same time pains in the joints occur, like those of rheumatism.. Over 
parts of the body the skin becomes red in patches, which may grow 
dark and even gangrenous. Crops of pustules also appear, one after 
another, on the face and limbs. In the course of a week or so, a 
muco-purulent discharge comes from the nostrils, which are swollen, 
ulcerated, or gangrenous. The fauces, pharynx, larynx, even the 
lungs, may become seriously involved. The face and eyes also inflame 
and become cedematous. Throughout, fever of a low form continues, 
with great thirst, delirium or coma, a fetid odor from the skin, and 
diarrhoea. Death almost always occurs within three weeks ; some- 
times one or two weeks later. 

Chronic glanders is rare ; it is described as milder than the above, 
and much less fatal. 

Treatment. — This must be purely tentative. Most worthy of trial 
are the sulphites, as sulphite of soda. Locally, I would use creasote 
dissolved in glycerin, — dilute chlorinated soda, and lime-water. 

INFLUENZA. 

Synonym. — Epidemic Catarrh, 

History. — Although, among persons exposed to the same weather, 
catarrhal affections are of course* common at certain times, there is 
evidence that, apart from the conditions of humidity and temperature 
of the air, epidemic catarrh sometimes occurs as a zymotic disease. 



DENGUE. 265 

It is recorded as having been quite fatal in France in 1311 and 1403 ; 
in 1570 also it prevailed, and in 1557 spread over Europe and extended 
to America. It occurred again in 1729, '43, '75, '82, 1833, '37, with 
notable violence. In the United States, one of the most remarkable 
epidemics, for extent, was that of 1843. The local prevalence of in- 
fluenza may occur at very irregular periods, and sometimes so mildly 
as not to be distinguished from common sporadic catarrh. 

Symptoms and Course. — The ordinary symptoms of " a bad cold" 
are those of influenza ; but the illness is somewhat more severe, and 
prostration is generally greater. Of this there are all grades, how- 
ever. Bronchitis, sometimes capillary, and pneumonia, are not rare 
complications. Old people are especially apt to be carried off by 
influenza. Its mortality is very small among persons in early or 
middle life. The duration of an attack is commonly from three to 
ten days. 

Causation. — The hypothesis has been entertained, in consequence 
of the irritating effect of ozone upon the air-passages, that an excess 
of it in the atmosphere may be the cause of influenza. But no facts 
raise the supposition beyond conjecture. 

Treatment. — Mild cases require housing, and little more. A warm 
mustard foot-bath at night, followed by a large draught of hot 
lemonade if there be chilliness, or the same taken cold if fever exist — 
and a dose of solution of citrate of magnesia or Rochelle salt or 
senna tea in the morning, will generally suffice. Sweet spirit of nitre 
may be added to the night-draught if the skin be dry and the urine 
scanty. 

Great prostration, especially in old people, may call for support, by 
quinine and stimulants. Hot whisky punch is, for such a case, not 
out of place. The abortion of an attack of influenza is sometimes 
practicable within the first two days, by giving quinine, in four grain 
doses, thrice daily. Bronchitis or pneumonia, as complications, will 
require treatment as in other cases. 

DENGUE. 

Synonym. — Break-bone Fever. 

History. — Frequently in the Southern United States, occasionally 
in the Northern (at least Dr. Rush seems to have described it at 
Philadelphia in 1780), and in the East and West Indies, this disorder 
has occurred. English writers regard it as a variety of scarlet fever ; 
naming it Scarlatina rheumatica. 

Symptoms and Course. — Usually after a chill, fever comes on, 
moderate in degree, but attended by considerable debility, and severe 
pains in the head, back and joints ; the latter being somewhat swollen. 
In about two days, or less, the fever subsides, and the pains lessen, 
though they do not disappear. Toward the end of a week from the 
commencement of the attack, a rash breaks out, resembling that of 
scarlatina, or duller and more in patches. The fever returns, often, 
about the fourth or fifth day, and lessens or ceases after the eruption 
has come out. All the symptoms gradually subside, leaving the 
patient well but very weak, by the beginning or middle of the second 
23 



266 ZYMOTIC DISEASES. 

week of the attack. This disease, without complication, is never 
fatal ; nor does it leave any sequela except debility. 

Its causation is not known, beyond what, is comprised under the 
term "epidemic influence." It is noticeable that it affects more 
persons at one place and time than almost any other epidemic ; nearly 
all the population may have it in one season ; all ages and both sexes 
being alike attacked. 

In treatment, dengue requires merely good nursing — regulating the 
bowels, and relieving or mitigating the pains with Dover's powder or 
other opiates, especially at night ; or by the local application of lauda- 
num, &c. 

MALARIAL FEVER. 

Varieties. — Intermittent, Remittent, and Pernicious Fever. These 
may all be properly regarded as grades or modifications of the same 
type of disease ; agreeing in the nature of their cause, the periodicity 
of their symptoms, and their mutual convertibility. Each will, how- 
ever, require a separate description. 

INTERMITTENT EEVER. 

Synonyms. — Ague ; Chills and Fever. 

Varieties. — Quotidian, when the paroxysm occurs every day; 
tertian, when it is every other day ; quartan, on the first and fourth 
days ; also, quintan, sextan, septan, and octan. The quotidian and 
tertian are common ; the octan, or weekly return of the attack, is not 
unfrequently met with ; the others are very rare. The time between 
two paroxysms is called the intermission (apyrexia) ; the period from 
the beginning of one chill to the beginning of the next is the interval. 
Paroxysms are sometimes double : as, double quotidian, with two 
paroxysms on one day ; double tertian, with a paroxysm every day, 
but those of every other day corresponding in time or character ; &c. 
These also are rare. I have, in a large number of cases of malarial 
fever, in the suburbs of Philadelphia, never met with a double parox- 
ysm of either type. 

Symptoms and Stages. — No disease has ordinarily so regular a 
succession of definite stages as intermittent fever ; viz., the cold, the 
hot, and the sweating stage. 

Cold Stage, or Chill. — Beginning with languor and yawning, a 
sensation of coldness comes on, often creeping and shivering, with 
chattering of the teeth and rigors or tremulous movements. The skin 
has a sunken appearance, and the lips and finger-ends may be blue. 
The sense of coldness does not prove a low temperature of the body ; 
which the thermometer sometimes shows to be even hotter than natu- 
ral. Thirst exists, with loss of appetite ; occasionally, vomiting. 
Headache, depression of spirits, and drowsiness are common. Per- 
spiration is absent, but the urine is abundant and nearly colorless, 
with a low specific gravity. The duration of a chill varies from ten 
minutes to two or three hours ; averaging not more than three quarters 
of an hour. 

Hot Stage ; pyrexia. — Gradually warmth is felt to return ; the 
shivering ceases ; a flush succeeds the pallor or lividness of the face. 



INTERMITTENT FEVER. 2GT 

A real increase of the heat of the surface is found by the thermometer ; 
reaching 105 to 110°; seldom more than 108°. The mouth becomes 
dry, the tongue furred ; vomiting is common, with total anorexia. 
Headache is apt to be violent; but delirium is rather exceptional. 
The pulse is accelerated, and generally strong and full. The bowels 
are constipated ; the skin dry, the urine scanty and high-colored. The 
hot stage may last from an hour or two to sixteen or eighteen hours. 

Sweating Stage. — This also comes on gradually ; the face first 
becoming moist ; then the trunk and limbs. This is attended by in- 
creased comfort; the headache lessens, the stomach if disturbed 
becomes quiet, the patient often goes to sleep and sweats profusely all 
over. After this, the fever has gone ; the pulse is slow and soft, the 
skin cool. The urine now again is passed freely, and deposits a brick- 
dust like (lateritious) sediment. There is no definite length of time 
to be assigned to the sweating stage. 

Of the three stages, now and then one or two may be wanting. 
There is then only a chill, or a fever, or a sweat, occurring daily, or 
every other day, at the same hour. Or, a paroxysm of pain may 
occur, in one part of the body, with the same regularity. One form 
of this is called " brow ague." Dumb ague is a popular name for an 
attack in which the chill is absent or obscure, the other symptoms 
recurring periodically. There seems to be no doubt that a single 
limb, or even a single finger, may go through all the three stages — 
cold, hot, and sweating ; the rest of the body being unaffected. Inter- 
mittent neuralgia is very common in malarial districts, especially 
after chills and fever. In the same regions, all complaints are apt to 
take on periodicity; so we may have intermittent dysentery, pneu- 
monia, etc. 

The intermission is often a time of apparent health, except some 
debility, and perhaps headache and want of appetite and of good 
digestion. 

The greater number of paroxysms of intermittent occur in the day 
time. An attack which began as a tertian, may become a quotidian ; 
or the converse may happen. Intermittent sometimes passes into 
remittent fever ; though much less often than remittent becomes in- 
termittent. 

Sequelae. — Protracted intermittents are often accompanied or 
followed by anaemia, of a marked character, and by enlargement of the 
spleen and liver; especially of the former. Dropsy is a quite frequent 
result of these visceral affections and of the anaemia. 

Morbid Anatomy.— Melanmmia, or pigmentary degeneration of the 
blood-corpuscles, with deposit of pigment granules in the liver, spleen, 
kidneys, brain, etc., is almost a characteristic of malarial disease. 
Enlargement and softening of the spleen, and engorgement of the liver, 
with a bronzed appearance of it, are the only other peculiar changes 
of structure. 

Diagnosis. — One chill can hardly ever be certainly pronounced to 
be malarial, because very many acute disorders begin with a cold stage. 
Two, with a distinct apyrexia, cannot often be confounded with any- 
thing else, except hectic fever. In the latter, there is usually a known 
cause for the symptomatic febrile symptoms ; the patient is weak and 






268 ZYMOTIC DISEASES. 

emaciated, the paroxysm is irregular in time and duration, there is a 
bright roseate flush upon the cheek, and headache is usually absent. 

Prognosis. — Left to itself, intermittent will sometimes get well as 
early as the seventh, eighth, or ninth paroxysm ; more often it will 
last ten weeks ; sometimes for as many or more months. 

When under treatment, it is almost always possible to break the 
chills by cinchonization; but they frequently return ; especially at the 
end of one, two, or three weeks. It is a good sign for the paroxysm 
to occur later and later in the day, and to become shorter and shorter. 
Tertian ague is generally the most readily cured ; quartan the most 
intractable, though comparatively uncommon. Death, in modern 
times, since the discovery of the properties of Peruvian bark, almost 
never happens from the ordinary type of intermittent ; the pernicious 
form is very dangerous. 

Pathological Nature. — As to this, it is possible only to speculate 
at present. It is most probable that ague is a toxcemic neurosis. 

Causation. — Upon the origin of malarial fevers, the following facts 
seem to be established : — 

1. They are reasonably designated as autumnal fevers, because 
very much the largest number of cases occur in the fall of the year. 
Spring has the next greatest number of cases. 

2. They are always strictly localized in prevalence. 

3. They never prevail in the thickly built portions of cities. 

4. An average summer heat of at least 60° for two months is neces- 
sary to their development. Their violence and mortality are greatest, 
however, in tropical and sub-tropical climates. 

5. They prevail least where the surface of the earth is rocky ; and 
most near marshes, shallow lakes and slow streams. The vicinity of 
the sea is free from them, unless marshes lie near it. 

6. The draining of dams or ponds, and the first culture of new soil, 
often originates them. 

7. Their local prevalence in the autumn is always checked by a de- 
cided frost. 

Upon these facts, it was a legitimate hypothesis (urged especially 
by the late Prof. J. K. Mitchell of this city) that the material cause 
of malarial fevers is a minute vegetative organism, whose substance 
or emanations enter the body. Professor Hannon of Brussels re- 
lates that he learned in 1843 from Prof. C. Morsen, and verified the 
statement in his own person, that the exhalations of certain fresh 
water algas would produce ague. 

Dr. Salisbury of Ohio has recorded in the January number of the 
American Journal of Medical Sciences for 1866, some observations 
and experiments, tending to show that minute cryptogamic plants of 
the family of Palmelhe, abounding over the surface of marshes, can 
generate intermittent fever, when transported to localities otherwise 
free from it. Such results require of course repeated investigation to 
make them actually matters of demonstration. When confirmed by 
such means, they will make a very important contribution to etiology. 

Treatment. — One remedy, in this disease, overshadows all others ; 
cinchonism. By this we mean, the production of the constitutional 
impression of the cinchona bark, or of one of its essential constituents. 



INTERMITTENT FEVER. 269 

At any stage it appears to be safe, unless it be the very height of the 
pyrexia. Nor, as a rule, is aDy special preparation necessary. 

It is well, always, during the chill, to promote speedy reaction by 
external warmth, and perhaps by hot drinks, of a not too stimulating 
character. The bowels ought to be opened well ; and the stage of 
fever may be palliated by the free drinking of cold water, made more 
diaphoretic by the addition, if necessary, of neutral mixture or effer- 
vescing draught. Then, as soon as sweating fairly begins, the quinia, 
or cinchonia, or bark in substance, may be prescribed. 

The sulphate of quinine has the most universal reliance. Some 
give it in doses of several grains each, twice daily. I think experi- 
ence warrants me in preferring to give one grain every hour [F. 2, 
159]. The amount required in the intermission of ordinary intermit- 
tent is about fifteen grains. Less may often cure, but can hardly be 
depended on. The quinine may be given in pill or in solution. I 
direct that, in tertian ague, the patient begin early on the day of the 
intermission, and take one grain every hour till he has taken twelve 
grains. The next day let him begin at the same rate and. if no chill 
occur, take ten grains. The third day, nine; and so diminishing 
daily until six grains are reached. , Let this be continued till a week 
from the last chill, when a greater tendency to a return will exist ; on 
that day let ten grains again be given. After that time, if no par- 
oxysm has occurred, he is, for the time at least, well. 

Sulphate of cinchonia, in doses one-half greater (gr. jss instead of 
one grain) [F. 160, 161] has always succeeded with me, in a con- 
siderable number of cases ; as it has with others. It generally pro- 
duces much less ringing in the ears than quinine, and can be taken 
by some whose heads do not well bear that medicine. Quinidia, quino- 
idine, and other extractives of bark I have not tried, and would prefer 
not to trust ; though some favorable experience with them is recorded. 
Bark in substance, especially Calisaya bark (an ounce in the inter- 
mission), is of course perfectly reliable ; but it is disagreeable and 
oppressive to the stomach, and should only be used when its deriva- 
tives cannot be obtained. 

Other remedies in considerable number, have obtained more or less 
reputation in the treatment of ague. Opium, given in full dose (say 
60 drops of laudanum) shortly before the time of an expected chill, 
has been found generally to abort it. Arsenic (10 drops of Fowlers 
solution thrice daily) is considered to approach very nearly in cer- 
tainty to the preparations from cinchona. Sulphate of copper is 
asserted by some (in | grain doses) to be antiperiodic ; and so is nitric 
acid (10 drops thrice daily, diluted) ; and common salt (a drachm at 
a dose, half an ounce during an intermission). Dogwood bark; pep- 
per, and its extractive, piperin ; willow bark, and salicin obtained from 
it, have also some reputation of the same kind. Chloroform, taken 
by the mouth, has recently been used with success by Dr. Merrill. 
He gives ftj at once, at the beginning of the chill. It may be diluted 
with mucilage. 1 A strong impression of almost any kind, upon the 

1 Pollacion and others in Spain have found the internal use of chloroform 
successful in intermittent. Bonafont reports the cure of fifteen cases by in- 
halation of chloroform. — Dublin Quar. Jour, of Med. Set., Feb. 1867. p. 167. 

23* 



270 ZYMOTIC DISEASES 

system, during the apyrexia, may arrest or prevent the paroxysm. 
So may act the drawing of a blister upon the spine ; or a cold shower 
bath. I have known one case to be cured by the patient being 
solemnly assured (without medicine) by a quack that " he would never 
have another chill." 

But the breaking or interruption of chills, though generally cura- 
tive of a first attack, is not nearly always so in a second or third. 

Chronic intermittent may maintain a constant tendency to relapse, 
in spite of cinchonism. In such a case, anaemia, and the malarial 
cachexia, are usually present. Here the great remedy is iron. This 
has never disappointed me ; that is, I have never failed to cure a case 
of uncomplicated chronic intermittent, even of several months' dura- 
tion, by breaking the chills first with quinine, and then causing the 
patient to persevere for a month or two with iron. I prefer the pill 
of the carbonate, Yalleix's mass ; with a grain of quinine in each pill 
[F. 162]. 

KEMITTENT FEVER. 

Synonym. — Bilious Fever. 

Varieties. — Simple and malignant. The latter, however, will be 
described under Pernicious Fever. 

Symptoms and Course. — Although the premonitory stage is usually 
short, and not unfrequently wanting, its general occurrence is well 
established. Its symptoms are those of general malaise, with some 
headache, slight nausea, and furred tongue. These increase until a 
chill, not violent, but lasting sometimes half an hour or an hour, fairly 
begins the attack. Or, an ill-defined cold stage, with a feeling of 
chilliness, languor, and debility, and perhaps cerebral oppression and 
gastric disorder, may occur. 

After this, the febrile condition is developed. The skin becomes 
hot, dry, and harsh ; the pulse rises in force and frequency, although 
less hard and tense than in some diseases, and not exceeding gener- 
ally, during the first exacerbation, 110 or 115 beats in the minute. 
The face is flushed ; headache is throbbing and severe; the faculties 
being unfitted for any mental exercise. Violent pain is almost always 
felt in the back, and very often also in the limbs. Epigastric uneasi- 
ness is nearly universal; nausea and vomiting extremely common. 
Bilious matter is in many instances ejected from the stomach. The 
bowels are costive ; when opened, however, the stools are colored with 
bile. The urinary secretion is scanty. Thirst is always great ; cold 
drinks being much preferred. Respiration is hurried, although free. 

After a continuance of from eight to twenty hours, these symptoms 
abate more or less, even without treatment. The feelings of the pa- 
tient are more comfortable; he sleeps; and wakes with a skin less 
hot, and moist, perhaps even with considerable perspiration. Head- 
ache, however, and some pain in the back remain ; and the pulse does 
not subside to the natural standard. In some instances it is little 
altered. The stomach, however, is less disturbed, and thirst is some- 
what less intense. 

There is reason to believe that a few cases of genuine miasmatic 



REMITTENT FEVER. 271 

remittent may, by prompt treatment during the hot stage, be quelled, 
so as not to advance beyond the first exacerbation and remission. 
We ascribe their facility in yielding, chiefly, to a less degree of in- 
tensity in the morbific cause. 

Mostly, in from six to twenty-four hours, the patient's discomfort 
again increases ; the skin becoming even hotter than before, and quite 
dry ; the pulse rises to 120 in the minute ; thirst is great, although 
sometimes less than in the first paroxysm ; the headache returns, 
and with it usually severe pain in the back. The tongue is now 
thickly furred, often with a yellowish hue. Nausea and disgust for 
food are again felt, and in a large number of cases vomiting returns; 
the stomach rejecting everything, even cold water. The stools, when 
obtained, are sometimes slate-colored ; but more often decidedly 
colored with bile. Diarrhoea is uncommon, and is most apt to accom- 
pany a later stage. Delirium is common only in violent cases ; rest- 
lessness is almost universal. Yellowness of the skm appears in a 
majority, in various degrees. 

The advance of the disease, after the second paroxysm, is exceed- 
ingly various. The periodical character, however, is maintained 
throughout. The remissions may occur at any hour, — in moderate 
cases being as often in the afternoon as in the morning ; in the pro- 
tracted, more commonly in the morning, the fever lasting through the 
night. Quite frequently a double tertian type is observed ; the 
exacerbation occurring one day in the morning, and the next in the 
afternoon ; and sometimes with different degrees of violence. 

Duration. — Favorable cases often terminate in six or seven days 
in an intermission, which in some becomes a cure even without any anti- 
periodic treatment. The more violent, especially if ill-managed or in 
an abnormal constitution, may be protracted for three, four, or occa- 
sionally five or six weeks. We should distinguish, however, between 
the true periodical disease and its sequelae. The average duration of 
a case of remittent fever may be stated as about fourteen days. 

Complications. — These are usually dependent on local inflamma- 
tions. The brain is perhaps the organ most frequently affected, with 
cerebritis or meningitis. In late autumn, or other cool weather, 
pneumonia is not uncommon. Gastritis and enteritis, — diarrhoea 
and dysentery of an obstinate character sometimes occur. When any 
of these affections exist, they partake to some extent of the periodical 
character of the fever ; and are often lessened or removed by the 
treatment adapted to it. In other cases, however, they remain in a 
subacute or chronic form ; and, when death occurs, in a majority of 
instances the immediate cause is a violent phlegmasia of some organ. 
Hepatitis and splenitis are more common in the chronic form than in 
the acute, — and as sequelae rather than complications of the attack. 

The Typhoid State. — At any time after the fourth or fifth day, but 
particularly near the end of the second week, a patient suffering with 
remittent fever may pass into the condition designated by the above 
term. Its features vary somewhat ; but it is usually marked as fol- 
lows : Pulse 120 to 140, and rather deficient in strength ; skin harsh, 
varying, however, with the slight remissions in dryness and tempera- 
ture ; face dark or flushed ; head hot; delirium, active more frequently 
than comatose ; bowels occasionally affected with diarrhoea, but us 



212 ZYMOTIC DISEASES. 

often costive ; tongue heavily coated with sordes, brown or black, and 
with cracks or fissures across it. Muscular debility is usually great. 
Hemorrhages from the bowels, lungs, or stomach occasionally increase 
the danger. 

The chief causes of this condition are, 1. Neglect of treatment in 
the early stage. 2, The premature and improper use of stimulants, 
or even, in some cases, of tonics, without previous depletion. 3. The 
existence of cerebral inflammation. 4. In the opinion of some, a par- 
ticular epidemic tendency to the typhous condition, in all diseases, at 
certain times. 5. In the view of others, the concurrent existence of 
a true continued fever, making a sort of hybrid. 

Modes of Termination. — These are, either, 1. Recovery in a week 
or two directly from the febrile state ; 2. Conversion into a distinctly 
intermitting fever; 3. Cessation of the fever with remaining organic 
inflammation or other disease ; or, 4. Death during the progress of 
the fever. 

The first of these occurs sometimes even when the onset has been 
violent, and the circulation much disturbed. How frequent its spon- 
taneous occurrence might be, is difficult to determine under ordinary 
practice in miasmatic regions; where the first intermission is made 
use of to introduce anti-periodic remedies. But it appears that 
remittent fever may much oftener be cured by antiphlogistic treat- 
ment alone, than intermittent. 

The rule, however, with many historians of the disease is, to consider 
that favorable cases terminate in curable intermittent. This change 
is generally accompanied by a discharge from some excretory organ 
or surface, with propriety termed critical. Copious perspiration ; free 
urination, with a lateritious or other thick deposit ; the discharge of 
abundant, dark, offensive stools ; one or all of these, may precede or 
accompany the commencing improvement of symptoms. 

A local inflammation, as pneumonia, enteritis, cerebritis, or hepatitis, 
may survive the attack which kindled it, and proceed as if it had been 
an original malady. 

Where death occurs within the first three weeks, it is almost always 
the result of some inflammatory complication. Remittent fever rarely 
proceeds to a fatal termination, in this vicinity, by mere exhaustion 
of the powers of nature. In feeble or aged persons, however, this 
may occur. 

Sequelae. — A slow and imperfect convalescence not unfrequently 
follows a violent attack ; attended with sallowness of the skin, feeble 
digestion, muscular and nervous debility. The only organic altera- 
tions at all constant are enlargements of the liver and spleen. 

Morbid. Anatomy- — The most striking observation upon this was 
that made at the Pennsylvania Hospital by Dr. T. Stewardson, in 
1841, of the unusual color of the liver; bronzed without and olive- 
green within. Subsequent confirmation of this has been afforded ; 
although Dr. Drake of Cincinnati failed to find it in his autopsies. 
The spleen is almost always enlarged, congested, and softened. In- 
flammation of different organs (making fatal complications), especi- 
ally the brain, lungs, or bowels, may exhibit their usual results. Such 
lesions, however, are sometimes absent in the most malignant cases. 



REMITTENT FEVER. 273 

Causation.— This lias been considered already, under the head of 
intermittent fever. 

Diagnosis. — Yellow fever has by some physicians been regarded 
as identical with remittent, differing mainly in the grade of its violence. 
The correct view is, that they are specifically distinct diseases To 
prove this, we might be satisfied with the simple facts of the different 
localization of the two fevers. Remittent is always a country fever ; 
yellow fever almost invariably, a disease of towns and the vicinity of 
the sea. The latter is restricted much more narrowly, also, in its 
actual geographical limits. 

But there are symptomatic differences also ; which may be best 
pointed out after giving a description of yellow fever. Among the 
important points is, that one attack of the latter disease commonly 
gives immunity from it for life ; but this is not at all the case with 
remittent fever. 

When the typhoid state supervenes, there may exist very considera- 
ble similarity to the true typhoid fever. It is asserted that a coexist- 
ence of the two diseases occurs. Some, upon the same facts, ground 
the opinion that they are not specifically different; — but that typhoid 
fever is merely a protracted remittent of low form. This is however 
contradicted clearly by at least two facts : 1, the comparative rarity 
of typhoid fever in regions where remittent most abounds ; and 2, the 
frequent prevalence of the typhoid where remittent fever is almost 
unknown ; as in some of the Eastern States. 

The mode of onset in the two, moreover, is usually quite different ; 
in typhoid, insidious and almost imperceptible at first ; in bilious fever, 
after a day or two of malaise, a chill abruptly ushers in the attack. 
Vomiting is extremely common in the one, — quite rare in the other; 
the converse is true of diarrhoea, — and still more particularly of 
tympanites and abdominal tenderness. The deafness, and sleeping 
stupor, — and livid countenance of typhoid fever, are almost entirely 
peculiar. Epistaxis, bronchitis, and the rose-colored eruption, so 
nearly constant in the latter, are rare in the typhoid remittent ; the 
last mentioned is perhaps never observed. The yellowness of the skin, 
also, and the distinct remissions, mark well the remittent attack. In 
dissection, we find more gastric and hepatic change after bilious fever, 
and more enteric and splenic alteration in the typhoid. 

Prognosis. — Recovery may be anticipated in a majority of instances. 
The writer is of the opinion that the typhoid prolongation of the 
attack ought scarcely ever to occur, under proper treatment from the 
beginning. Before the use of cinchona, remittent was often quite 
fatal. Alexander the Great, Emperor Charles V., James L, and 
Cromwell are said to have died of it. 

Favorable signs are, the earlier occurrence and prolongation of the 
remission, and its becoming more and more complete ; moistening and 
clearing of the tongue ; copious perspiration ; turbidness of the urine, 
from increase in the amount of its solids ; tar-like and offensive stools; 
and the appearance of vesicles about the lips. 

Unfavorable, of course, are, the shortening and postponement of 
the remission, and its indistinctness, dryness, and blackness of the 
tongue ; retention, or still worse, suppression of urine ; extreme fre- 
quency, with weakness of the pulse ; hiccough ; and other important 



274 ZYMOTIC DISEASES. 

evidences of the victory of disease over the vital functions, — not, 
however, peculiar to the fatal termination of this disease. The super- 
vention of the usual symptoms of inflammation of the brain are 
always very alarming ; gastritis may occasionally threaten to wear out 
the patient's strength ; and pneumonia is attended with more danger 
when occurring as a complication of fever, than when an original 
disease. 

Treatment. — In sections where it is very prevalent, this disease 
has been subjected to a variety of experimental practice — pushed, in 
some States, with a boldness and energy characteristic of border popu- 
lations. At one time, the early use of large doses of tartar emetic to 
produce vomiting; at another, of calomel, administered by the half 
ounce or ounce ; and, recently, of quinine with corresponding extrava- 
gance — have been the methods used, until fairly proved to be needless 
or improper in violence. 

The other extreme, however, of trusting all to nature, would meet 
with more signal disappointment in this than in many other affections. 
A decided treatment is imperatively required ; what then are its best 
and most promising weapons ? It would be interesting and instructive 
to collate and compare many authorities upon this point ; but we will 
discuss the subject in reference, chiefly, to the experience of our own 
physicians. It will be proper to state the valuable testimony of Dr. 
Drake, to the mode of practice which the separate judgment and ob- 
servation of medical men throughout the great Western Valley now 
converge upon. "Its fundamental principles," he states, "are — that 
autumnal fever is the product of a specific cause, and, therefore, con- 
sists in a morbid action of a peculiar kind, requiring a specific remedy ; 
that we possess such an antidote for the intermittent variety of the 
fever ; and that we have only to abate all the causes and points of 
difference between the two varieties, to render the sulphate of quinine 
as efficacious in one as in the other." 

No clearer or more correct expression need be demanded, we believe, 
for the safest and best plan of management of our own fall fevers. 
Yet many voices may demur at this assertion. 

Some will quarrel with the terms of the above paragraph ; objecting, 
and with some force, that we go beyond what is known in proclaiming 
the specific nature of the cause of these fevers — and still more in 
awarding the name of antidote to the sulphate of quinine or Peru- 
vian bark. But this is a verbal question. We do know that mias- 
matic fevers are quite peculiar — in locality — in periodicity, and in 
other characters ; and we do know that the salts of the alkaloids 
obtained from cinchona control and arrest them, as few if any other 
remedies can — and with a power which those salts do not exert over 
other fevers. 

This power, however designated or explained, is now fully acknow- 
ledged amongst us ; the danger is, in fact, of its causing us to lose 
sight of other important points. 

In some tropical latitudes, especially, in which venesection is not, 
comparatively, well borne — and in districts poisoned with malignant 
miasm — it has been proved that quinine is often required in liberal doses 
— is borne in very large ones — and acts favorably even without any of 



REMITTENT FEVER. 275 

the depletory and sedative preparation of the system, once thought in- 
dispensable. These facts have been fully proved. But the remaining 
questions to be settled are — is not success greater in remitting fever, 
even in those regions, if some evacuant (and reducing) treatment at 
least accompanies the use of the great remedy ? — and — is not a modi- 
fied treatment at least in this respect necessary in less malignant cases, 
and different climate. 

The weight of evidence favors the affirmative of both of these 
questions. 

It remains, then, to state in a few words, what is the plan of treat- 
ment proper to be adopted. 

The physician is rarely called until the febrile condition has fairly 
set in. 

In a person of robust constitution, if the headache be very severe, 
skin hot and pulse full as well as rapid, venesection will be safe at 
least. But it is much more common now to administer first a saline 
cathartic, and decide on the grade and resistance of the fever by its 
effect. Epsom salts will be the best when the stomach is little dis- 
turbed — the Seidlitz powders in repeated doses under contrary cir- 
cumstances may answer. But many commence the treatment with a 
dose of calomel or blue pill with rhubarb, to be followed by a saline 
purge. If obstinate vomiting prevail, as will frequently happen, no 
purgative will suit so admirably as the effervescing solution of the 
citrate of magnesia. If a second exacerbation occurs with increased 
violence after a slight remission, in a robust person, venesection may 
be performed ; but the amount taken should be moderate. The utility 
in many cases of leeches or cups to the nucha, and sometimes to the 
epigastrium, is undoubted. 

As a refrigerant diaphoretic, the citrate of potash solution, with or 
without effervescence, may be constantly given. 

Special treatment may often be called for by the great intractability 
and distress of stomach. Lime-water or magnesia in small doses with 
ammonia and an aromatic will frequently relieve. 

Sinapisms and pediluvia are of course useful adjuvants. Ice will 
answer better to quench thirst than water, where gastric irritability 
is great ; otherwise free dilution by drink is an advantage. 

As soon as the violence of systemic excitement has been moderated, — 
without waiting for its entire subjugation, — if the pulse has begun to 
subside, — lowering for instance from 110 or 120 to 90 or 100, and the 
headache is less intense, — the bowels freely moved, — we may begin 
with quinine ; but it is unnecessary here to give large doses generally. 
Unless where some malignancy is suspected, or the remission is 
very complete, a single grain every two hours will be sufficient at 
first. Under this, after the reducing measures, we may find the pulse 
continue to subside, — the skin to moisten, and all the symptoms to 
improve. At all events in the next remission the dose should be in- 
creased to a grain every hour, — not, as a general rule, however, 
awaking the patient from sleep. Two grains every hour for eighteen 
hours, is the freest administration I have ever seen to be necessary 
in a case even threatening malignancy. This term, it need hardly be 
said, is used to express the existence of a state of prostration attended 



276 ZYMOTIC DISEASES. 

with signs of visceral congestion, increasing dangerously with each 
paroxysm ; reaction being deficient, as we believe, from an unusual in- 
tensity of the morbid cause, — or defect of constitution. Such cases 
do require a large amount of the special remedy ; and such cases are 
no doubt much more frequent in warmer southern States than here. 
We have no difficulty in believing in the toleration, — or even the pro- 
priety of considerably larger doses than are here given ; but there is a 
limit even there, to go beyond which, is excess. Perhaps we should 
allow somewhat in the estimate in some remote places, for the immense 
adulteration of valuable drugs which prevails. 

After two or three days of constant " quininization" — the amount, 
usually, may be diminished to six or eight grains distributed through 
the day. In rather smaller quantities it should be continued even 
through the period of convalescence. 

The treatment of inflammatory or other complications must of 
course superadd modifications appropriate to each. We have named 
in the above sketch all the main elements of the plan which is found 
successful in such cases as ordinarily occur. 

The existence of local inflammations, in a genuine miasmatic case, 
does not contraindicate the use of quinine. Being lit up by the fever- 
poison, — and aggravated by its febrile state, the treatment which 
annuls or removes these will often lower or check the phlegmasia. 
But this maxim should be applied with caution and some exceptions, 
in cases particularly of cerebral inflammation, or great pulmonic op- 
pression. 

In slow convalescence, with sallowness and deranged digestion, the 
daily administration for a few days of minute doses of blue mass gene- 
rally proves useful. And, to improve sanguification, as well as lessen 
the danger of relapse in some form, the protocarbonate of iron, in pill 
with a portion of sulphate of quinine, will make a very valuable termi- 
nation of the treatment Arsenic may also sometimes be required. 

PERNICIOUS FEVER. 

Synonyms. — Congestive Fever; Malignant Intermittent; Malig- 
nant Remittent. 

Symptoms and Course. — Unlike ordinary intermittent, a paroxysm 
of the pernicious form may commence either in the day or at night- 
At first, however, in many cases, it begins like the common type of 
chills and fever, or remittent fever ; after one, two, or three days be- 
coming more alarming. 

Then, the skin grows lividly pale, shrunken, and sometimes clammy 
with cold sweat ; the countenance anxious ; the tongue either pale, 
furred, or natural ; in the worst cases it is cold. Thirst is intense, 
with a sense of internal heat. The stomach is excessively irritable, 
and vomiting very common, of mucus, or a muco-serous or even 
bloody fluid. The bowels are in most cases loose, the dejections 
resembling bloody water. The pulse is usually small, weak, and rapid 
or irregular ; in a few instances corded. The respiration is inter- 
rupted and sighing, with a sense of oppression. 

Restlessness is common ; but the mental faculties in many cases are 
clear. There are, however, many others in which the weight of the 



PERNICIOUS FEVER. 21*1 

attack falls on the brain. Then, the early symptoms are drowsiness 
and hesitation of speech. Stupor marks the depth of the paroxysm. 
The breathing may be stertorous ; or tetanic spasms may occur. The 
pulse, in the former case, may be slower than in the other form de- 
scribed ; but it is still weak, and, even if the head be somewhat warm, 
the vessels of the neck and temples are not apt to be swollen, and the 
skin of the body is cold. 

Partial, or, it may be, complete reaction in most instances follows 
after three or four hours of the above symptoms ; though death may, 
instead, take place in the collapse. Again the fever may intermit, or 
remit ; — and, at the same or an earlier hour the next day, another 
paroxysm occurs. This is more dangerous than the first. If a third 
be allowed to take place, it is generally fatal. 

Morbid. Anatomy. — Congestion, of the brain, liver, spleen, and 
alimentary mucous membranes, is so prominent an autopsic phe- 
nomenon as, with the symptomatic appearances of the same, to have 
seemed to justify the older and more common name of the disease. 
We have good reason to believe, however, that the toxaemic impres- 
sion of malaria, and its effects upon the nerve-centres (either of 
organic or of animal life), are primary, and the congestion secondary. 

Diagnosis. — The intensity of the symptoms, and the general pros- 
tration, or coma, will distinguish this from ordinary intermittent or 
remittent. The condition of a severe case is not unlike an attack of 
epidemic cholera ; but the discharges are different ; and the locality 
and season, unless in the presence of that epidemic, will point directly 
to malarial causation. 

As pernicious fever is rare in the latitude of Philadelphia (much 
more common farther south, especially near the rice plantations of 
the Southern States), I have seen but two or three cases of it. One 
of them gave me difficulty in diagnosticating it from apoplectic coma ; 
as it occurred in a lady over sixty years of age. The distinctness of 
the cold stage at the beginning of the attack, and my knowledge of 
the patient's history, and the possibility of exposure to malaria, led 
me to prescribe quinine with some freedom ; and the result established 
the nature of the case, as entire recovery followed. 

Prognosis. — Without appropriate treatment, a large majority of 
cases would be fatal. There are few diseases displaying a greater 
tendency to death. Under cinchonism, and other proper management, 
not more than one in eight probably die. 

Treatment. — As above implied, quinine is our great reliance in 
this disease. Larger doses are required, also, than in ordinary inter- 
mittent. While opinions differ, the best evidence I can obtain con- 
vinces me, that from thirty to sixty grains of quinine in twenty-four 
hours will do all that the remedy can do ; more will be wasteful and 
dangerous. 

But, in most cases, other means must be employed, sometimes before 
quinine can be kept upon the stomach, to promote reaction. External 
stimulation is foremost among these means. Direct heat may be 
applied, by hot-water bottles or tins, hot bricks, or bags of hot salt 
laid along the spine. Thirst should at the same time be quenched by 
cold water, or, if the sense of heat is great, and vomiting occur, with 
24 



278 ZYMOTIC DISEASES. 

ice. Mustard plasters may be placed upon the spine, epigastrium, or 
limbs ; or the extremities may be rubbed with brandy and red pepper. 

The opposite of this plan is preferred by some, upon asserted favor- 
able experience, viz., the pouring or dashing of cold water quickly 
upon the naked body. Extensive dry cupping along the spine is 
recommended by others. From what I have seen of the good effects 
of dry cupping along the spine in the collapse of cholera, in one case, 
I should have some confidence in it for this analogous condition. 

Internal stimulation also is demanded under the same circumstances. 
Most used have been camphor, opium, ether, oil of turpentine, ammo- 
nia, and capsicum [F. 163] ; besides wine and brandy or whisky. The 
best testimony is in favor of camphor and opium, with quinine [F. 
164], in moderate doses every half hour during the chill, when no 
comatose symptoms are present. If these exist, oil of turpentine, by 
the mouth or rectum, has its decided advocates. 

Calomel has been largely used in the same cases. My experience 
in pernicious fever has not afforded me data for an opinion about it ; 
but I respect the evidence of those who think they have seen it to be 
beneficial. I should give it, in the dose of a grain, every three hours, 
at least. 

Alcoholic stimulants seem to be indicated in the collapse. A table- 
spoonful of brandy or whisky every half hour or hour until reaction 
occurs would be a suitable average. 

After reaction has been established, even imperfectly, and an inter- 
mission or remission exists, the " sheet anchor" is quinine. Then, if 
the stomach bear it, five to ten grains may be given every two or 
three hours, until cinchonism is fully established. When the quinine 
is rejected by the stomach, hypodermic injection may be resorted to. 
Ten grains or more may be introduced at once, in solution in water 
with sulphuric acid enough to dissolve it perfectly. 

In the cerebral cases, calomel is particularly appropriate. A blister 
to the nucha may be recommended in the same case. Purgatives are 
also apt to be required ; and, if the heat of the head be great, iced 
water may be kept applied over it, while hot bottles or sinapisms are 
put in contact with the legs or feet. 

When the critical period in pernicious fever has been passed, it will 
need treatment like an ordinary case of intermittent or remittent, 
according to the type which it assumes. A modification of this affec- 
tion, sometimes called "winter fever" in the South, has been already 
considered under the head of typhoid pneumonia. 

PROPHYLAXIS OF MALARIAL FEVER. 

When avoidance of malarial localities is impossible, during the 
season of fevers (from July until frost in some parts, of the United 
States, from the first of August at least, in this vicinity), exposure 
should be especially guarded against at night, and just before and 
after sunrise and sunset. Residents in such places should have a fire 
burning to dry the house whenever the weather is damp, whatever the 
season. Going into a marshy place with an empty stomach is very 
exposing. 

Quinine may be used as a prophylactic. Livingstone and Du Chaillu 
have tried it in Africa ; the former too sparingly to succeed perfectly; 






TYPHO-MALARIAL FEVER. 279 

the latter with better results. In the United States army during the 
late war it was found useful. Six grains daily is the least amount to 
be relied upon. 

TYPHO-MALARIAL FEVER. 

Trusting that this, having had its origin in the circumstances 
of the late war, may be now altogether a matter of history, it yet re- 
quires a place among recognized diseases. It was the result of a three- 
fold causation ; the elements of which were malarial influence, crowd- 
poison, and scorbutic taint. According to the predominance of one 
or the other of these, its character in different cases was determined. 
During service in a United States General Hospital, in the summer 
and fall of 1862, as well as in the Episcopal Hospital, I saw many 
cases of this, called from its local origination the Chickahominy 
fever. 1 Of the form in which the malarial element predominated, the 
somewhat abrupt commencement, gastric disturbance, and icteroid 
skin and tongue, with remissions, for a while at least, tolerably dis- 
tinct, were prominent features. The lenticular spots of typhoid fever, 
and the sudamina and tympanites were often wanting altogether. 

A slower onset, less distinct remissions, more cerebral disturbance 
and diarrhoea, with epistaxis and bronchitis sometimes, but with both 
less constantly than in civil life, marked the predominance of the 
typhoid pathogenetic element. Deafness, under my observation, was 
less frequent than in civil life, but was sometimes very well marked. 
The aspect of the countenance, and the character of the somnolence 
and delirium, were precisely the same as in ordinary typhoid fever. 

The scorbutic complication was recognizable, in the third group of 
cases, by the peculiar mental and bodily prostration which preceded 
and followed the disease — the remarkable irritability of the heart, the 
state of the gums, tendency to hemorrhage, discolorations and pete- 
chias, pallid, large and smooth tongue, and extremely protracted con- 
valescence. 

Morbid Anatomy. — Most of importance was the intestinal lesion, 
similar to that of typhoid or " enteric " fever, though not identical. 
The following account of this is from Dr. Woodward. 3 

" In the earlier stages there is little to distinguish the intestinal 
lesion from the corresponding process of ordinary enteric fever, except 
perhaps the great tendency to the deposit of black pigment in the 
enlarged follicles. In the later stages, certain peculiarities are often 
distinctive enough to enable the anatomist to recognize typho-malarial 
fever by the post-mortem appearances alone. The tumefaction in 
typho-malarial fever rises very gradually from the surrounding mucous 
membrane, and attains a moderate degree of thickness (three to six 
lines) on the edges of the ulcer. In this it differs materially from the 
ordinary typhoid ulcer, in which the enlarged patch rises abruptly 
from the mucous membrane in such a way that the summit is often 
larger than the constricted base, giving rise to the comparison made 
by Rokitansky, who likens the shape of the tumefaction to that of 

1 A full account of all varieties of typho-malarial fever is given in Dr. J. J. 
Woodward's "Camp Diseases of the United States Army." 
3 Op. citat., pp. 102-3. 



280 ZYMOTIC DISEASES. 

flat, sessile fungi. The umbilicated depression, so frequent in the 
ordinary typhoid patches prior to ulceration, has never been observed 
in typho-malarial fever. The ulcer itself presents ragged, irregular 
edges, which are often extensively undermined in consequence of the 
erosion extending more widely in the submucous connective tissue 
than in the glandular tissue of the mucous membrane. This charac- 
teristic undermining of the edges is much more extensive in these than 
in ordinary typhous ulcers." 

Pathology. — Doubting not at all the presence of the malarial ele- 
ment, the question occurs, was the modifying " febrile" cause of the 
typhous or of the typhoid character ? Granting, that is, that these are 
pathogenetically distinct, we should expect that the typhous or 
" crowd-poisoning" element must result from the circumstances, as 
from those which have made typhus or " camp fever" the scourge of 
armies in Europe. Only, against this, we have the local lesion, of the 
glands of Peyer and mucous membrane of the bowels, recalling enteric 
or typhoid fever. 

But, as, where typho-malarial fever occurred, causes of intestinal 
irritation (bad water, deficient food, &c.) were present, — I am not 
satisfied that such an appearance (not, as we have seen, identical 
with that of typhoid fever) should exclude the idea of the action being 
that of the typhous cause. In that opinion, as a probability, not, of 
course, now demonstrable, I rest. 

Treatment. — From the above view of the hybrid and threefold 
nature of the disease, came its rational treatment. More quinine than 
in typhus, more alcohol than in remittent, more fresh vegetable food 
and fruit than in either. Experience justified this plan. In our hos- 
pitals, in Philadelphia, few died from fever who were not moribund on 
their arrival from the seat of war. 

YELLOW FEVER. 

Only certain localities have ever been subject to this disease ; and 
of those, most have had it but occasionally. In Philadelphia, it first 
appeared in 1699 ; then in 1741, 1747, 1762, 1793, 1819, 1820, 1853, 
1854, and 1855 ; the last visitations being to a very moderate extent. 
The worst epidemic at New Orleans, where it has been frequent 
(almost annual), was in 1853. Sanitary measures, under General 
Butler's military rule, in 1862, appeared to avert it, in that city, under 
circumstances which might have been expected to promote it. A very 
severe visitation of yellow fever occurred at Norfolk and Portsmouth, 
Virginia, in 1855. 

All the places which it has ever visited are upon the borders of the 
Atlantic Ocean, or its tributary waters, the Gulf of Mexico and the 
Mediterranean Sea. Although with like climatic conditions, it is com- 
mon in the West Indies and west Africa, but unknown in the East 
Indies, the eastern shore of Africa, and the Pacific coast of America. 

Symptoms and Course. — With an abrupt beginning, or an indis- 
tinct cold stage, with pains in the back or limbs, commencing often 
in the night, a febrile stage occurs, of long average duration ; some- 
times three days without remission. Violent cases have it snorter ; 
sometimes lasting only a few hours. 



YELLOW FEVER. 281 

The skin, at this period, is hot and dry. Thirst is extreme; the 
tongue is generally furred. Nausea and vomiting are common on the 
second day, with great epigastric tenderness. The bowels are costive ; 
if discharges occur they are very offensive. 

A flush of the forehead, with a fiery look of the eyes, is character- 
istic. Delirium is frequently present. Violent headache is nearly 
universal. 

The stage which follows this pyrexia is a sort of remission or in- 
termission. All the symptoms abate except the epigastric ten- 
derness. The flush of the face and other portions of the skin is 
succeeded by yellowness, which grows deeper as the disease advances. 
The pulse grows slower, heat abates, respiration becomes natural in 
frequency, the patient sits up and feels better. This state of things 
lasts for a variable time, averaging about twelve hours. 

Sometimes convalescence now takes place. Much more often a 
third stage succeeds, of prostration or collapse. Muscular debility 
becomes great ; the pulse is rapid, irregular, and compressible ; the 
capillary circulation sluggish ; the skin deep yellow or bronzed ; the 
tongue brown ; the stomach excessively irritable. It is at this time 
that the black vomit occurs, which is pathognomonic of this fever. 
Hemorrhages may also occur from the mouth, throat, or bowels. The 
mind grows apathetic, or low muttering delirium exists. In bad cases, 
which are many, hiccough, clammy sweats, convulsions, and involuntary 
discharges precede dissolution. Death most frequently occurs on the 
fourth, fifth, or sixth day. 

When reaction from the collapse takes place, there follows a second- 
ary fever, of very variable duration, and which may terminate in a 
tedious convalescence, an almost equally prolonged typhoid condition, 
or death by exhaustion. 

Black Vomit. — This has been found, upon chemical and micro- 
scopical examination, to consist essentially of blood, altered by action 
of the fluids of the stomach. It is usually acid to test-paper. 

The urine, in yellow fever, is scanty and high colored at the begin- 
ning, and especially deficient in amount from the third to the fifth 
day. About the fourth day, it becomes cloudy and deposits a sedi- 
ment. Granular tube-casts from the kidneys may be discovered in it 
on the fifth day. Blood and bile may also appear in it; as well as 
large amounts of creatin or creatinin. Urea is apt to be below the 
normal quantity. 

Morbid Anatomy. — Congestion of the brain is not uncommon ; 
inflammation of the stomach is usual. The liver is most frequently 
dry, pale yellow, and anemic ; but occasionally it is engorged. Fatty 
accumulation in the liver has been repeatedly observed ; and exudation 
into it is asserted. The spleen is little altered ; the kidneys are always 
congested. 

Diagnosis. — The only doubt likely to be entertained is as to its 
identity (or that of an example of it) with bilious remittent fever. As 
already remarked, the latter is a disease of the country, in any warm 
quarter of the globe. Yellow fever is restricted geographically, and 
is but seldom met with except in towns and near the sea. The order 
of stages in the two diseases is different ; remittent never has a pyrexia 
lasting over twenty-four hours without mitigation. There is more 

24* 



282 ZYMOTIC DISEASES. 

epigastric tenderness in yellow fever. The jaundiced hue of the skin 
is more commonly met with, and more decided, in that disease. The 
black vomit, when it occurs, is decisive. Possibly, even probably, in 
a few localities, the combined causation of the two fevers may pro- 
duce hybridity between them. Immunity for a lifetime after one 
attack is common with yellow fever ; not at all with remittent. 

Prognosis. — This is a very dangerous disease ; the deaths from it 
averaging about one for three cases. A long and moderate febrile 
paroxysm, without excessive irritation of the stomach, is favorable. 
So is the occurrence of secondary fever instead of collapse, after the 
remission. Black vomit is almost always a fatal sign. Some instances 
of the disease are called walking cases, because their early symptoms 
are slight, only the countenance and pulse betraying the danger, until 
near the end. 

Pathology and Causation. — There seems no room to doubt that 
yellow fever is a zymotic disease, whose cause is generated by certain 
local conditions. That cause must be itself material ; and, probably, 
being slow and limited in transportation, it is a microscopic vegetation. 

The local conditions observed are, 1. Continued high heat ; about 
80° for one or two months. 2. Excess of moisture in the air; a high 
dew-point. 3. Vicinity to the sea, or to a large river emptying into 
the sea. 4. Organic, especially vegetable, matter in a state of de- 
composition. This is furnished not only by the offal, etc., of cities, 
but by decaying wharves and causeways (as at Norfolk, Ya.), and by 
newly upturned earth. Mobile was almost relieved of danger from 
yellow fever by paving the city with oyster shells. 

But it is very remarkable, as already stated, that certain quarters, 
only, of the globe ever have this disease, though presenting all the 
above conditions. It never visits the Pacific coasts either of America 1 
or Asia. Canton, Calcutta, Bombay, Alexandria, Constantinople, and 
Athens, have never seen it. Nor have any of the interior cities of 
either continent. It visits often the western coast of Africa, the 
tropical islands of the Atlantic, the north coast of Sfcouth America, 
Yera Cruz, the West India islands, New Orleans, Savannah, Charles- 
ton ; occasionally, Rio Janeiro, Natchez, Mobile, and other United 
States ports and cities, as far north as Boston and Providence ; also, 
Gibraltar, Marseilles, and other places on the Mediterranean, as far 
as Sicily. 

The contagiousness of yellow fever, from person to person, is dis- 
proved by the immense preponderance of facts incompatible with it. 
A very few apparent examples of transmission by individuals, if 
admitted to have occurred, are otherwise explained. Transportation 
by ships is admitted, because a ship may carry a section, as it were, 
of a locality, with all its conditions and atmosphere. But, then, the 
port to which the ship goes must have all the conditions rife for the 
propagation of the disease, or its " germs" will not be maintained so 
as to cause an epidemic. 2 More will be said of this, under the head 
of Prophylaxis. 

1 A single instance of its occurrence on sbip-board off the west coast of South 
America has been asserted. If so, no doubt it was a case of limited transpor- 
tation. 

2 On the whole subject of yellow fever, see La Roche's exhaustive treatise. 



YELLOW FEVER. 283 

Treatment. — No specific has been found for yellow fever, and no 
abortive treatment. All kinds of remedies have been tried for this in 
vain ; especially bleeding, calomel, and quinine. I say in vain as to 
cutting it short ; but in palliating and conducting it through ks stages 
with safety, those and other remedies may be of use. Bleeding is sug- 
gested by the relief often attending spontaneous hemorrhages in its 
course ; but, as in other malignant affections, the cases for it must be 
well selected, the time early, and the amount moderate. Much the 
greatest number will gain only by the application of leeches or cups 
to the epigastrium or back of the neck. 

Many authorities approve of the use of calomel as a cholagogue 
cathartic, at least in a single dose (say of three or five grains), followed 
by a saline laxative, as citrate of magnesia, near the beginning of the 
attack. All the result of the use of quinine of which I feel sure is, 
that it is not likely to do good at any early stage, but only when pros- 
tration begins to appear ; and then in tonic or supporting, not cinclio- 
nizing doses. It is undoubtedly of service during convalescence. 

Attention to the stomach is demanded by urgent symptoms. Ice, 
by the mouth, is refreshing and useful. So is mineral water, or iced 
champagne, a little and often ; lime-water, charcoal water, and hot 
coffee have sometimes done service in arresting vomiting. A mustard 
or spice plaster over the epigastrium, or a blister dressed with acetate 
of morphia, may have an important effect upon the same symptom. 

During the hot stage, cold sponging to the face, body, and limbs, 
will sometimes promote perspiration better than any other measure. 
Enemata of cold water (with care not to chill too powerfully) has 
been used for the same end. 

In the collapse, stimulation will be needed, by wine, brandy, or 
whisky, etc. ; along with concentrated liquid food, in small amounts at 
short intervals. 

The experiments with anti-septic and anti-zymotic substances, as 
chlorine and the sulphites, made with other affections analogous to 
yellow fever, might be properly tried with it also. I am not acquainted 
with any such trials as yet. 

Prophylaxis. — Besides what has been said, the following state- 
ments will indicate the principles of prevention of this disorder : — 

1. The infection of yellow fever is rarely diffused over regions of 
great extent ; mostly its limits may be measured by fractions of a 
square mile. 

2. The removal of the inhabitants of an infected spot will inevitably 
put an end to an endemic or epidemic of it. 

3. Sanitary police may effectually prevent it (as at New Orleans 
under General Butler), and will mitigate it even after its outbreak. 

4. The material cause of yellow fever is never generated or multi- 
plied in the bodies of those having the disease ; they may be taken 
anywhere without fear of communicating it, any more than well 
persons. 

5. The germs of the disease are extremely seldom, if ever, trans- 
ported by f omit es ; i. e., clothing, bedding, merchandise, etc. If it 
exist in any such material, it is certainly destructible by cleansing and 
disinfecting measures. 

6. A ship may carry yellow fever on board of it for a length of time 



284 ZYMOTIC DISEASES. 

(during warm weather) and to a great distance ; but the disease will 
not spread far from the ship ; at least unless favorable local conditions 
add their propagating influence. 

7. Thorough airing, cleansing, and disinfection of ships (especially 
by dry heat or superheated steam) will always deprive them of the 
power to generate or transport yellow fever. 

8. Against yellow fever, the true prophylactic method must be that 
of sanitary police ; a part of which should be, the inspection, near 
ports liable to it. of all vessels arriving during warm weather. 

9. At the place of such inspection, all foul vessels should be de- 
tained until cleansed, being first emptied of their passengers and cargo. 
The cargo also should be inspected, and, if unwholesome, destroyed 
or disinfected. 

10. No personal detention whatever, other than of those ill, for 
necessary hospital treatment, should be imposed upon the passengers 
or crew of vessels which have yellow fever on board. There are no 
facts which give reason for any such detention. 

RELAPSING FEVER. 

Never yet met with in the United States, unless a few times in 
emigrants, but little need here be said of this disease. By excellent 
British authority, it is ascribed directly to famine ; sometimes being 
called " famine fever." 

After an indistinct premonitory stage of a few days, or else abruptly, 
the attack begins with a cold stage, often having decided rigors ; a 
chill. There is then fever, with pain in the stomach, vomiting, 
and prostration ; sometimes petechial spots over the body. On the 
fifth or seventh day great amendment appears ; this seems to progress 
favorably, until, about the fourteenth day from the beginning, a relapse 
occurs, with fever and prostration. This again gives way generally 
in three or four days, and is followed in a majority of cases by con- 
valescence. The mortality in Great Britain is estimated at one in 
forty. 

Treatment. — No specific being known, mild palliative management 
is called for. This may be described, in the words of a late author, 
as consisting of " gentle aperients, refrigerating drinks, liquid diet, 
perfect repose," and quinine, in tonic doses, from the middle of the 
attack, though with no hope of its acting to prevent the relapse. 
Other palliatives will be suggested by particular symptoms in the 
course of the disease. 

CEREBROSPINAL FEVER. 

Synonyms. — Cerebrospinal Meningitis ; Spotted Fever. The name 
adopted above is preferred by me, in the absence of sufficient prepon- 
derance of authority or reason in favor of either of the other names. 
The disease is a fever, or systemic disorder ; not a mere local phlegma- 
sia. It has no more claim to be called cerebro-spinal meningitis than 
typhoid fever has to be called enteritis, or scarlet fever faucio-pharyn- 
gitis. Yet the term spotted (or petechial, Wood) fever is not fully 
justified as distinctive — because, only in a minority of cases it ex- 



CEREBROSPINAL FEVER. 285 

hibits any eruption, and something like the same is also at times seen 
in typhus. 

History. — Often obscurely described, this disease appears to have 
been known in France in 1310 and 1482 ; over Europe, or parts of it, 
in 1503 '10, '16, '17, '28, '45, '59, (Sicily) '64, '68, (Paris) '69— '74. In 
1580, it was at Rome, Venice, and Madrid, with great mortality ; 
again over Europe in 1582; at Trent, 1591, Florence, 1592, at various 
places, 1616 and 1624. Sydenham described it in 1661. In 1691 and 
'93 it was in Italy; and in England, 1698, 1710, 1741: in Prussia, 
1704. Other years named for it are 1720, '60, '61 ; 1757 and 1778. A 
well-known outbreak of it occurred at Geneva, 1805 ; one in the Prus- 
sian army, 1806, '7 ; in Sicily, 1808 ; at Dantzic, 1811 ; Brest and 
Mayence, 1813, '14 ; Grenoble, 1814, and the same year at Paris ; 
1815 at Metz; elsewhere in 1816 and 1823. Afterwards in Europe 
its historians (under the names meningite cerebro-sptnale epidemtque, 
cerebral typhus, and tifo apoplettzco tetanico) speak of it in 1832, '37, 
'39, '40, and almost every year till 1850, extending over many places in 
succession as far as Gibraltar and Algiers at the south, and Scotland 
and Ireland at the north. From 1854 to 1861, in Sweden, Norway, 
and Holland. In north Germany and Russia, it is said to have pre- 
vailed in 1863, '4, '5. 

In the United States, its first recorded visitation was in 1806, in 
Massachusetts. Then it gradually spread through the New England 
States, New York, and Canada, from 1807 to 1812, when it had 
reached Philadelphia. After that it was met with at various places 
until 1820 ; but not with great frequency. Between 1840 and 1850 it 
was epidemic in several of the Middle, Western, and Southern States 
(Kentucky, Indiana, Illinois, Michigan, Missouri, Tennessee), also in 
1852 and 1858. Next we hear of it in 1862-3 ; most clearly in the 
descriptions of Dr. Gerhard in the latter year, as it occurred in the 
neighborhood of Philadelphia. Since that time (at which cases were 
seen especially at Frankford, Falls of Schuylkill, Manayunk, and Nor- 
ristown, but only a few in the city) it has been observed in a number 
of places in Pennsylvania, New York, Ohio, Indiana, Michigan, Mis- 
souri, Rhode Island, Vermont, Massachusetts, Maryland, and the 
District of Columbia. 

Symptoms and Course. — The attack is nearly always sudden. 
Chilliness, terrible pain in the head, extending to the back of the neck, 
nausea and vomiting, are the earliest symptoms. Delirium follows ; 
ending not unfrequently in coma. Tetanic spasm or rigidity of the 
muscles of the back of the neck (and sometimes of the back and 
limbs), is common. Convulsions are much less so, but do occur, par- 
ticularly in the young. Painful sensitiveness (hyperaesthesia) of the 
whole surface of the body is present in most cases, where there is no 
coma. Loss of sight and hearing may take place during the middle 
period of the attack. The pulse is at first slow, then accelerated, but 
diminished in volume and strength. Respiration is slower than natural 
in most, but not in all cases. The tongue is usually at first white and 
moist ; sometimes natural ; in prolonged cases it may become yellow or 
brown. The bowels are costive or natural. 

The skin has almost always at the beginning an abnormally low tem- 
perature. When reaction occurs it does not become very hot as a 



286 ZYMOTIC DISEASES. 

rule. Dryness of the surface is most common, although late in the 
attack profuse perspiration may occur. 

In a minority of the cases, though varying in proportion in 
different epidemics, spots (petechia?) appear, on the second or third 
day, or later; on the neck, breast, or limbs; seldom on the face. 
They are of different dimensions, from the size of a pin's head to three- 
quarters of an inch in diameter, and distinct ; but not elevated nor 
disappearing on pressure. Their color is red, purple, or black. 
Sometimes they remain after death. They are either congested por- 
tions of the skin, or subcutaneous extravasations of blood. 

The duration of fatal cases of this disease is generally short. Some 
die in three or four hours ; many within twelve or twenty-four. That 
much time overpassed, the danger becomes less, but a fatal result 
may still occur, even after a number of days. The first four days are 
the most perilous to life. 

Morbid Anatomy. — The blood, during life, is found to have an ex- 
cessive proportionate amount of fibrin and corpuscles. After death, 
where it has taken place on the first or second day, no anatomical 
changes, even in the brain, have, in several instances, been found. 
Most generally, however, the brain and spinal cord show some alter- 
ation. It is the pia mater especially in which congestion, at least, is 
nearly always present. At the base of the brain, most of all, is this, 
often with serous and plastic exudation, observed. The surface of the 
hemispheres may also be diseased ; and, next in frequency, the pia 
mater of the cervical portion of the cord. The ventricles of the brain 
have usually an excess of fluid in them ; serum, either clear or mingled 
with blood or pus. The substance of the brain is more or less injected 
or congested ; the spinal cord occasionally so. Softening of the brain 
is reported in protracted cases. 

No other lesion or appearance is shown to be usual in this disease. 
A few observers record the presence of rather firm fibrinous clots in 
the heart. 

Diagnosis. — From typhus fever, this is known by the suddenness 
of its onset, the early period of danger, and, in favorable cases, the 
rapid recovery; as well as by the peculiarity of the eruption. From 
ordinary iuflammation of the brain, while the diagnosis may be very 
difficult, it differs in the unexplained abrupt attack, severe from the 
start; in the lowness of temperature during the first day or two ; in 
the early tetanic tendency ; and the eruption in many cases. Malig- 
nant scarlet fever resembles it considerably at the onset ; and so does 
the chill of pernicious intermittent. Locality and season will designate 
the latter ; age and exposure, especially, the former. Fortunately, 
the principle of treatment is not essentially different in these affections, 
at the stage which may present a doubt. 

Prognosis. — More than half the cases die. Those who survive 
three days, have a fair, though not certain, prospect of recovery. 

Causation. — Of either sex, more children, and of adults, more males, 
die of this disease. Coincident with the circumstances of war, or 
military regime, most of its epidemics have been, though not all of 
them. The analogy which it presents to typhus suggests a probable 
relation of the disease in causation to local or atmospheric contami- 



TYPHUS FEVER. 287 

nation. I can think of only one plausible hypothesis ; that it depends 
upon a peculiar zymotic material, or " morbid poison/' generated by 
a slow change in human or animal emanations, such as, in camp or 
garrison life, the long un-washed clothing of soldiers may particularly 
engender. 

There is no proof whatever of personal contagiousness in cerebro- 
spinal fever. 

Treatment. — We must lament the unsatisfactory condition of the 
evidence upon this subject. Almost all agree that asthenia charac- 
terizes the disease, most of all at the beginning. The resemblance to 
pernicious fever has suggested the use of quinine. And several very 
positive statements of success are made, with it in large doses ; as, 
two to four grains every hour or half-hour until cinchonism is pro- 
duced, or until from thirty to sixty grains have been taken ; afterwards, 
a grain or two every two or three hours. Some other practitioners, 
upon trial, have abjured quinine altogether in this disease. Were my 
diagnosis sure in every case from the commencement, I should feel 
compelled to renew the trial of it, from what has been reported, in this 
city particularly, of its success. 

Opium has equally enthusiastic advocates and opposers. Early, if 
it be given, must be the time. The idea of those who urge it is, to 
give of it a grain every two or three hours, until an opium sleep is 
produced ; then withdraw it or give it in much less doses. 

Stimulation with brandy or whisky is generally employed in the first 
stage, with freedom. External stimulation is also, of course, indicated 
by mustard, direct heat, friction with red pepper and brandy, or hot 
whisky and salt, &c. Dry cupping, or in some cases cut cups (when 
reaction occurs) to the back of the neck, will be proper ; followed by 
a blister at the same place. 

Cantharides (20 to 40 drops of the tincture, every hour till reaction), 
camphor, chloroform, sulphite of soda, and bromide of potassium, have 
each had laudation from some who have used them. But more positive 
experience is needed to give the profession much confidence in the 
treatment of this affection.' 

TYPHUS FEVER. 

Synonyms. — Ship Fever; Camp Fever ; Jail Fever. 

Symptoms and Course. — For a day or two, premonitory weakness, 
headache, and loss of appetite occur. Then a cold stage, of variable 
distinctness, begins the attack. In rare instances, it is said that death 
takes place in this, without reaction. Much more commonly, fever 
follows ; with severe headache, great heat of skin, pulse 120 (110 to 
130), but compressible, tongue whitish or yellowish, bowels costive. 
Delirium is common, especially at night. The temperature in the 
axilla is from 102° to 108° ; generally, after the third day, 105°-6° 
in the morning, 106°-7° in the evening. Muscular debility is very 
decided. 

1 See J. S. Jewell, M.D., Report on Cerebro-Spinal Meningitis, Chicago, 
1866 ; and J. J. Levick, M D., " Report on Spotted ITever, so called," Trans. 
Am. Med. Assoc. 1866. 






288 ZYMOTIC DISEASES. 



For a number of days this condition lasts ; the patient lying in a 
stupid half-sleep much of the time, muttering to himself, easily 
roused, but soon lapsing again ; the face having a dusky flush of red- 
ness. Hardness of hearing is present in most cases. Positive coma 
is a very bad prognostic, but is not infrequent. Suppression of urine 
may take place in the worst cases ; retention occurs in many severe 
ones. The tongue grows darker as the attack progresses ; brown, even 
black ; often cracked or fissured ; and it as well as the teeth may be 
covered with sordes. 

Towards the end of the first week, in most cases, a rash appears, 
of little and numerous red papulse (miliary eruption), all over the 
chest, abdomen, and upper parts of the limbs. They are accompanied 
by sudamina (minute vesicles) in many instances, by petechias in a few. 
Sometimes a strong odor comes from the body ; but I have never 
noticed this, even in the cases of ship-fever from Ireland in the Penn- 
sylvania Hospital, in 1847-8, at which time I took the disease myself 
from them. 

The urine is scanty. Generally it contains an excess of urea and 
uric acid, with a deficiency of the chlorides. Sometimes there is 
actually less than the normal amount of urea eliminated; when 
excreta may be supposed to accumulate in the blood, promoting coma. 
Gostiveness is the general rule in typhus. 

The dicrotous or double pulse, and subsultus or twitching of the 
tendons at the wrist, are common. Weakness of the impulse of the 
heart is often noticeable; sometimes so much so as to justify Dr. 
Stokes' diagnosis of " typhous softening." Hypostatic pneumonia 
(i. e., beginning with passive congestion of the lungs posteriorly), is 
the most frequent complication of the fever. 

The duration of an attack of typhus is generally three weeks. 
The critical period is usually about the eleventh day; after which 
defervescence (the decline of the fever) may be looked for. Occa- 
sionally death may take place within five days, or recovery within 
fifteen, from the commencement. 

Morbid Anatomy. — Absence of lesion of the solids has been re- 
peatedly noticed. The blood is always altered during life ; after the 
early stage, it is less coagulable and darker in color than in health. 
Passive congestion in various organs is observed, as in the lungs, brain, 
liver, &c, but without anything characteristic. 

Pathology and Causation. — No disease affords more reason for 
pronouncing it a disease of the blood than typhus. Its cause, demon- 
strably in many cases, is ochlesis or crowd poison ; the effluvia from 
human bodies, accumulated, especially in cold weather, in small and 
ill-built dwellings of the poor, and most of all in filthy towns, ships, 
jails, or camps. Having once been thus generated, it becomes conta- 
gious ; one patient having, in his morbid emanations, the poisoning 
power of a whole crowd. Yet the contagion is not very strong; 
many who are exposed often escaping the disease. 

Diagnosis, — After the first two or three days (during which there 
may well be doubt as to its character) the only probable question 
will be between typhus and typhoid fever. All medical authorities 
are not yet agreed as to the non-identity of the two forms of slow 



TYPHUS FEVER. 289 

continued fever. 1 A large majority, however, regard them as quite 
distinguishable during life, and separated pathologically by the absence 
in typhus of the morbid alterations of Peyer's glands, and those of 
the mesentery, characteristic of typhoid fever. I have many times 
seen typhus and typhoid cases in the same ward, lying side by side, 
and should feel confident of being generally able to point out which 
was which by the countenance alone. Under the head of Typhoid 
Fever, the clinical differences will be enumerated. 

Prognosis. — Murchison states the mortality in the hospitals of 
Great Britain, from typhus, to be one death in five cases. Cheyne 
and others in private practice have found it but one in twenty or more. 
I have not seen many deaths from it, in private or hospital practice. 
Probably one in ten or fifteen would be a fair general estimate. Bad 
signs are, great feebleness or extreme rapidity of the pulse ; profound 
coma; hiccough; suppression of the urine; involuntary defecation. 
Pneumonia complicating the attack increases its danger, though I 
have known several recoveries notwithstanding this. 

Treatment. — More than half the cases of typhus, according to my 
observation, require alcoholic stimulation, as well as concentrated 
nourishment, after the fourth day. But not all the cases ; as my own, 
among others, proved. I was bled on the second day, the diagnosis 
not being made out ; and leeched on the third day, freely, on the back 
of the neck ; yet no stimulus was required, after the typhous nature of 
the attack was clearly shown; recovery following at the usual time. 

We may begin the treatment of an ordinary case of typhus with a 
mild laxative, — e. g. a moderate dose of solution of citrate of magnesia, 
on the second day. The diet at first may be of gruel, toast-water, 
etc. ; but very soon must milk and beef-tea or chicken or mutton broth 
(or an alternation of these) be given to support the strength. Before 
the first week is out, half the cases will need wine in moderation ; 
some, brandy or whisky. In the second and third week, more than 
half the cases will require steady support of a positive kind. In such 
cases, the proper routine is, a tablespoonful of brandy or whisky 
punch (one part of spirit to three, two, or one of milk) every two 
hours, and, the alternate hours, a tablespoonful or two of beef essence 
or beef-tea. 

Of medicines, quinine has had the most extended trial in typhus. 
It acts well as a tonic, in one or two grain doses, four or five times 
daily, after defervescence has begun ; i. e., after the tenth or twelfth 

1 Dr. J. Hughes Bennett, for example, still maintains their identity ; and 
some German writers call typhoid "abdominal typhus." The definite history 
of typhoid or " enteric" fever began with Prost, of Paris, 1804. Louis, 1829, 
studied it elaborately, showing the constancy of the intestinal lesions. In 1833, 
Dr. Enoch Hale, of Massachusetts, described two forms of continued fever. Dr. 
Gerhard, upon careful autopsies in the Philadelphia Hospital, announced 
evidence of the distinctness of typhus from the typhoid or M dothinenterite" of 
Louis, in 1835. Dr. A. P. Stewart, of Glasgow, published similar conclusions 
in the same year. In 1846, Dr. W. Jenner commenced an investigation into 
the subject, whose results most physicians have accepted as decisive. He con- 
cluded that typhus and typhoid fevers are clinically and anatomically distinct, 
as well as different in causation. Dr. Gairdner has lately recorded cases in 
which patients convalescent from typhoid fever have taken typhus upon expo- 
sure to its contagion. 
25 



290 ZYMOTIC DISEASES. 

day usually. Dr. Dundas' plan of treating typhus early with large 
doses of quinine is, I am satisfied after seeing some trial of it, futile 
and even dangerous. 

Mineral acids have acquired much reputation in typhus. Nitro- 
muriatic acid I have known to produce an excellent effect in the 
depression of the middle stage. Large doses are not required ; but 
the acid should be given several times in the day. Some prefer dilute 
nitric acid [F. 165, 166]. Chlorine water, is lauded highly by some. 
The sulphite of soda may be worthy of trial. 

But the great point of skill will be to determine when and how far 
to stimulate. Delirium favors the probability of its being needed ; 
especially a low, muttering delirium. Of course a very feeble pulse 
indicates it. On trial, if the pulse grows slower, the skin more moist, 
and the restlessness or delirium is quieted, the stimulus has done 
good, and should be continued. If, on the contrary, a more hurried 
or a harder pulse follow, with heat of head and dryness of skin, and 
wilder delirium or deeper stupor, it should be stopped, for awhile at 
least, or if given be diminished in amount. 

Catheterism may be needed for retention of urine. Inquiry and 
inspection should determine every day the state of the bladder. 
Constipation, through the attack, may be overcome by enemata, or 
by small doses of oil, Eochelle salt, or other mild laxative. 

When the coma is very deep, a blister to the back of the neck may 
do good ; as well as sinapisms to the extremities. Great heat of the 
head may render proper, especially in the first week, the application 
of cold water to the head. Sponging the whole body daily (best at 
night) with whisky and water, warmed, is extremely comforting and 
beneficial. 

Hypostatic pneumonia, in typhus, cannot be treated actively. 
Even abstraction of blood by cups is hardly ever to be ventured upon. 
Dry cups, between the shoulders, and a blister upon the breast, are 
about all the special treatment allowable. It is, however, possible 
generally to prevent hypostatic pneumonia, by not allowing the patient 
ever to lie for many hours together upon his back. Let him be turned, 
once in awhile, upon one or the other side. 

Prophylaxis. — Thorough ventilation is the one security against the 
generation of typhus fever ; and this is capable also of almost disarming 
its contagion. 

TYPHOID FEVER. 

Synonyms. — Slow Nervous Fever ; Common Continued Fever; 
Enteric Fever ; Abdominal Typhus (Pythogenic fever of Murchison). 

Symptoms and Course. — After a more gradual approach than 
that of any other fever, with languor and debility, anorexia and head- 
ache, for several days, — bleeding at the nose, and a bronchial cough 
are almost pathognomonic early symptoms. The patient takes to 
bed, with fever of considerable violence. The face acquires a dark 
purple flush. He lies dozing, perhaps muttering, unless disturbed, all 
day ; but is more or less wakeful and delirious at night. Hardness of 
hearing is common from the middle of the second week. Swelling of 
the belly (tympanites) comes on towards the end of the first week ; 



TYPHOID FEVER. 291 

diarrhoea about the same time. Rose-colored lenticular spots (taches 
rouges), disappearing on pressure, are discoverable, few in number, 
and on the abdomen only, toward the end of the second week ; they 
continue a week or two. Tenderness on pressure in the right iliac 
region, with gurgling under the hand, generally exists. Sudamina 
over the chest are not unusual. The duration of the typhoid pyrexia 
is seldom, from the start, much less than two weeks, and it is often 
more ; the whole attack of typhoid fever may be protracted, as I have 
seen it, to two or three months. One month may be considered the 
average time, from taking to bed to leaving it convalescent. 

Late symptoms in severe cases are, the dicrotous pulse, subsultus 
tendinum, retention (perhaps suppression) of urine, hemorrhage from 
the bowels ; and, if death be imminent, hiccough, cold sweats, involun- 
tary discharges. 

In protracted cases, great emaciation and bed-sores may supervene. 
Even during convalescence, abscesses in various parts of the body 
may give trouble. These usually affect the glands or connective 
tissue, but may occasionally involve the long bones. 

Danger of perforation of the intestine, from deep ulceration of the 
glands of Peyer, exists always after the first week, until late in con- 
valescence. Patients out of bed for a week or two have sometimes 
died, after imprudence, from this cause. The occurrence of perforation 
is recognized by symptoms of severe peritonitis, with collapse. The 
result of this is almost inevitably fatal; the only recorded exception 
being reported by Prof. G. B. Wood. I saw a case of suppurative 
peritonitis, opeuing externally, which recovered, in the Philadelphia 
Hospital, several years ago ; but I was not able to learn the antecedents 
of the case. 

Temperature. — This has, of late, been made a special study in 
typhoid fever. The rise from 98.5° (the normal degree) is gradual, 
during the first four or five days ; reaching 104° on the evening of the 
latter ; sometimes 104.5°. An attack of disease in which on the 
second day the heat in the axilla is as high as 104°, is not typhoid 
fever ; and the same exclusion applies if from the fourth to the eleventh 
day the temperature falls below 103°. A difference of 1° or 1.5° 
between morning and evening (greatest heat, the latter) is usual; the 
reverse is not a good sign. Toward the end of the second week, low- 
ering of the heat below 103° is always favorable ; persistence at 104°, 
105° or 106°, shows a severe case ; the higher the worse. Sudden 
increase of temperature indicates a complicating inflammation ; as 
pneumonia. 

Discharges. — Liquidity of the stools is a characteristic of this dis- 
ease, even if there be but one daily. Generally, after the middle of 
the first week, there are two or three passages, brownish with a slight 
yellowish tinge every day. From the very beginning of the attack, 
the bowels are unusally susceptible to the action of purgatives ; a tea- 
spoonful of castor oil operating readily. Excessive diarrhoea, at a 
middle or late stage, not unfrequently adds to the prostration of the 
patient. Hemorrhage from the bowels, when it occurs, is most apt 
to be met with in the second or third week. 

The urine,, through the attack, is commonly scanty, high colored, 



292 ZYMOTIC DISEASES. 

excessive in the amount of urea, deficient in the chlorides, and some- 
times albuminous in severe cases. 

Complications. — Pneumonia, especially the hypostatic form (as in 
typhus) is the most frequent. It has been, by some writers, denied 
that true pneumonitis, anything more than passive congestion, occurs 
in these cases. But, in the analogous instance of typho-malarial fever, 
especially when the scorbutic diathesis was also present, I have seen, 
after death, more than once, suppuration, as well as hepatization, con- 
fined altogether to the posterior portions of both lungs. I do not 
doubt the same happening in typhoid as well as in typhus fever. 

Inflammation of the brain may complicate typhoid, more often than 
typhus ; but still it is not common. 

Peritonitis follows always when perforation of the ileum takes 
place. Examples of its occurrence without that accident are said to 
have been, though very rarely, observed. 

Sequelae. — Prolonged debility, or a very slow convalescence, is 
common. The mental faculties are sometimes enfeebled for weeks or 
months. Paralysis is an occasional sequela. Abscesses have been 
mentioned. Periostitis, followed by necrosis, of the tibia, femur, or 
humerus, may happen, though I have known of but two such cases. 
Perforation of the bowel may, as already stated, occur after convales- 
cence has seemed to be established. 

Morbid Anatomy. — Omitting variable and unessential or occasional 
appearances, the parts characteristically affected in typhoid fever are, 
the agminated glands or patches of Peyer in the small intestine, the 
mesenteric glands, and the spleen. Careful study of Peyer's glands, 
by many observers, has shown that, at first, the glands thicken and 
become elevated from one to three lines above the membrane around 
them. They are generally at this time reddened ; but with variable 
depth of hue. Sometimes, after this, a sort of induration occurs ; in 
other instances, softening. Later, ulceration affects many, though not 
all, of the altered glands ; and this process may go on until, as above 
said, it may perforate all the coats of the intestine. This, however, is ex- 
ceptional. The healing of the ulcers by granulation is the general rule. 

The solitary closed glands of the small intestine are also commonly 
enlarged, and often softened or ulcerated. The mesenteric glands are 
almost uniformly enlarged, congested, and softened ; occasionally they 
suppurate. 

The muscles, especially the recti abdominis, in protracted cases, have 
been shown to undergo a granular, or sometimes a waxy or amyloid de- 
generation ; resulting, in the rectus, occasionally, in rupture of its fibres. 

Pathology. — Typhoid fever is believed by most authorities to be a 
general or systemic disorder, with a characteristic secondary local 
lesion in the intestines. How far the matter deposited in the patches 
of Peyer before ulceration is specific, is a question. Eokitansky and 
Carl Wedl believe it to be peculiar, — the former comparing it to that 
of encephaloid cancer, the latter to tubercle. I do not believe that 
there is anything properly to be called specific in its nature. 

Dr. G. B. Wood holds the opinion that an inherent predisposition 
to the disease exists in many'persons, analogous to the tuberculous, 
gouty, and rheumatic diatheses. This seems to me very probable. 

Another view is, that the affection of the intestine is primary ; and 



TYPHOID FEVER. 293 

that the "typhoid" symptoms result from the absorption into the 
blood of morbid, putrescent material from the glands of Peyer, pro- 
ducing a septcemia or ichoreemia. This does not appear to me to be 
a reasonable hypothesis, in view of the order of events in the disease. 

Causation. — More doubt exists as to this in typhoid fever than in 
any other common disorder. Depressing causes of all kinds seem to 
promote it ; foul air, removal from home, fatigue, anxiety. &c. Yet 
it will occur in the entire absence of all such causes. No locality 
limits it ; all climates allow it ; from the Arctic regions to those border- 
ing upon the tropical ; from the cities of the East to the Rocky 
Mountains. The " mountain fever" of hunters in the far "West was 
found in the autopsies of Dr. Hammond to present the lesions of 
Peyer's and the mesenteric glands. 

Such universality is very much in the way of the "pythogenic" 
theory of Murchison (i. e. its reference always to foul air, as that of 
sewers), or that of Budd, that its only cause is a specific matter, 
passed from the bowels of those having it, and," by water or air, con- 
veyed into the systems of others. 

Contagion of this kind is, nevertheless, widely believed in now. es- 
pecially in England. Some facts asserted in proof of it are hard to 
explain without admitting such a mode of propagation (e.g., by the 
discharges of a patient getting into a well, etc., so as to contaminate 
drinking water). But the large majority of cases allow of no such 
explanation ; most of all those occurring in the open country. 

There is no doubt that typhoid and typhus fevers may coexist as 
epidemics ; sometimes affecting the same patient, the one fever shortly 
after the other (Gardiner) ; and occasionally together, as a hybrid 
disease. This may help us to account for some instances in which 
foul air has appeared to generate typhoid, and where the latter has 
seemed to be contagious. My own experience leads me to adopt the 
view expressed by Dr. Anstie, that "typhoid fever is certainly not 
contagious in the same sense as typhus is." 

Typhoid fever is rarest in old age ; not frequent in childhood ; most 
common between fifteen and thirty years. Few have it under ten or 
over forty; almost none beyond fifty. It scarcely ever (relapses 
apart) occurs a second time in the same person. 

Diagnosis. — From remittent fever, typhoid is known by the absence 
of vomiting and sallowness of the skin, the slower onset, more pro- 
tracted course, the hebetude or mental dulness and drowsiness, and 
the abdominal symptoms. 

From typhus fever, the distinctive points are as follows : 

In Typhus : Ix Typhoid ; 

No epistaxis or bronchitis ; Epistaxis and bronchitis ; 

Bowels constipated ; Diarrhoea ; 

Belly seldom tympanitic ; Tympanites, gurgling, &c. ; 

Miliary eruption, 5th to 7th day; Lenticular rose spots ; 
Progress moderately slow ; Progress very slow ; 

Death often within ten days ; Death rarely within fourteen days ; 

Countenance dusky red ; Countenance purplish red ; 

Causation mostly obvious ; Origin obscure ; 

Anatomy not peculiar ; Lesions characteristic. 

25* 



294 ZYMOTIC DISEASES, 

Cases called " febricula," or " irritative fever," (formerly ' ' synoehus") 
are described by some writers, and met with once in a while in prac- 
tice, which give a good deal of trouble in diagnosis. Some of these, 
probably most of them, are mild examples of typhoid fever. 

Prognosis. — The mortality from this disease varies greatly under 
different circumstances. The possibility of perforation of the ulcerated 
bowel gives an element of uncertainty to every case. Probably one 
death in twenty cases will represent its average mortality. The 
favorable and unfavorable symptoms, other than those common to 
typhus or other febrile affections, have been indicated sufficiently 
already, in our account of the disease. The state of the tongue es- 
pecially at the period of defervescence (end of second week, about) 
should be always noticed, as it aids our observation of the abdominal 
symptoms in concluding upon the progress of the intestinal lesion. 

Treatment. — Self-limited as typhoid fever is, no cutting short of it 
is possible. We must conduct the patient through it as safely as pos- 
sible. For this, little medication, perhaps none, will suffice, with good 
nursing, in many cases. I have treated the disease with so little 
medicine that it might be said to have been left to nature, supported 
by regulated liquid nourishment alone. Yet this is not always proper 
or safe. 

The course of treatment which I learned in the Pennsylvania Hospi- 
tal twenty years since, has been followed by me throughout my 
practice, with successful results. My only deviations from it have 
been in the direction of diminishing the amount of medicine given. It 
was, upon the average, as follows : — 

In the course of the first few days, if the bowels were costive, a tea- 
spoonful of castor oil was given ; after that, no laxative. During the 
first week, while the fever was highest, the tongue furred and often 
dry, skin hot and without perspiration, small doses of blue mass with 
ipecacuanha were prescribed, with the view of favoring freedom of the 
secretions. Afterwards, or at the same time, spiritus mindereri (liquor 
ammonia? acetatis) was given, a tablespoonful (diluted) every two or 
three hours, from noon till midnight, as a diaphoretic. 

Liquid food is necessary from the first. Oatmeal gruel, toast-water, 
rice-water, the first three or four days; then milk may be added, one 
or two tablespoonfuls every two or three hours. Less than half the 
cases of typhoid fever which I have seen have required alcoholic 
stimulation at any stage ; not more than one-fourth of the cases need 
it before the middle of the second week, when the fever begins to de- 
cline. After that time, many require it, first in wine whey, half a 
wineglassful about every three hours ; later, when weaker, brandy or 
whisky punch ; — a tablespoonful of brandy, for instance, every four, 
three, or two hours, sometimes every hour, with the same or twice as 
much of milk. Beef-tea is indispensable in nearly all cases, from the 
second week. It may alternate with punch, hour by hour. As in 
typhus, a patient prostrated with severe typhoid fever should be 
waked from sleep to take the required nourishment, night and day ; 
otherwise he will sink for want of it. 

Quinine, I am satisfied, has no place as a curative of this fever. It 
is useful as a tonic, after the critical period of the passing of the 



PLAGUE. 295 

height of the fever ; not more than eight or ten grains (in one or two 
grain closes) in twenty-four hours [F. 2]. 

In the first ten days, headache and heat of the head may call for 
the application of cold to it ; sometimes for leeches to the temples or 
back of the neck. Dryness and heat of the surface of the body may 
be best allayed by sponging all over (one part only uncovered at a 
time) with tepid whisky and water. This operation, done in the 
evening, will promote sleep. Great tenderness of the abdomen may 
be treated by application of large poultices of hot mush, with which 
one-fourth part of mustard has been stirred. 

Diarrhoea being a symptom of the disease, it needs not to be checked 
unless the passages number more than three or four a day, or are un- 
commonly copious. Then, a pill of tannic acid and opium (3 grs. of 
the former to gr. \ of the latter), pro re nata, — or small doses of 
paregoric or laudanum, will generally reduce it. Rarely is it neces- 
sary to use laudanum and starch enemata, or to add acetate of lead 
to opium in pill. Hemorrhage from the bowels is not apt to continue 
long, or to be dangerous. If it should, astringents, as lead and opium, 
by enema or by the mouth, must be used. 

Shall we attempt to medicate the affection of the glands of Peyer ? 
This also being symptomatic, its palliation only appears to be indi- 
cated. I am not satisfied that any special treatment for it is demanded 
in mild ordinary cases. But if, after the tenth or twelfth day, the defer- 
vescence does not take place, and restlessness is great, with abdominal 
tenderness, a dry tongue, and considerable diarrhoea, oil of turpentine 
is recommended by authority and experience. The dose should be 
not more than ten drops four times daily, in mucilage, with a few drops 
of laudanum. Nitrate of silver is used instead by some ; I have had 
no experience with it ; but I have often seen the good effects of turpen- 
tine. It seems to act as a local alterative to the ulcerated surface of 
the bowel. 

Attention to the state of the bladder, day by day, to prevent or 
relieve retention of the urine, is important. Long protracted cases 
may demand a great deal of care to avoid severe bed-sores. In antici- 
pation of these, when threatened, frequent changes of position should 
be made, and the parts should be bathed with whisky, spirits of camphor 
mixed with olive or lard oil, or soap liniment. The bed-clothes must be 
kept smooth under the person. Adjustment of pillows, with the addi- 
tion of small ones made for the purpose, may do much. When a part 
is unavoidably pressed upon, it may be protected by a piece of kid 
spread smoothly with soap plaster. Actual excoriations must be 
treated like ulcers, — with simple cerate, lime-water, poultices, adhesive 
plaster, etc., according to their condition. 

PLAGUE. 

Of this oriental disease, now fast being extinguished, little need 
be said here. It is a zymotic affection, allied to the fevers, of rapid 
course and great mortality. Its symptoms are debility, restlessness, 
fever, dyspepsia, vomiting, glandular swellings, especially in the ax- 
illa, or carbuncles. Death often takes place in two or three days. 

Plague was once thought to be the most contagious of diseases. 



296 ZYMOTIC DISEASES. 

Excellent reasons are given, however, for believing it not personally- 
contagious at all ; but locally infectious. Not quarantine, but sani- 
tary police and hygienic improvements in the great cities (Cairo in 
Egypt, for example) have almost put an end to it. 

In treatment of plague, diaphoretics, opiates, and mineral acids 
are best reported of. Polli's treatment with the sulphites might be 
tried in it with propriety. 

ERYSIPELAS. 

Synonyms. — St. Anthony's Fire; Rose. 

Varieties. — Traumatic and idiopathic. 

Symptoms. — These are both local and general. Sometimes the 
former and sometimes the latter appear first. Idiopathic erysipelas 
generally begins with an ill-defined cold stage, followed by fever. The 
eruption most often commences on the face, with soreness to the 
touch, and redness ; which spread like a slow conflagration, from part 
to part. This character of continuous diffusion or spreading is pa- 
thognomonic. Heat and moderate swelling attend the eruption. It 
may extend almost all over the body. It may also be superficial and 
transient, or the inflammation may involve the subcutaneous cellular 
tissue (especially on the limbs), causing suppuration and sloughing. 

The fever of erysipelas has no special features, nor has the disease 
any definite period of duration. When the scalp is the seat of the 
eruption, delirium is common, and inflammation of the brain, or fatal 
coma, may follow. Otherwise, the danger of the disease seems to be 
from suppression of the function of the skin, and exhaustion. Trau- 
matic or secondary erysipelas combines the danger of the disease 
itself with that of the injury, abscess, or other local affection from 
which it starts. Sthenic and asthenic forms or types of the disease 
may be discovered, according to constitution and circumstances. 

Erysipelas is often destructive in surgical hospitals, as an endemic 
or infectious malady. Ventilation and cleanliness will do much 
toward its prevention. Absolute contagion is not proved of it ; but the 
theory of " continuous molecular change" (Snow) applies very well to it. 
The immediate promotive cause of it would seem usually to be accu- 
mulation of effete material thrown off from the human body in con- 
nection with inflammation. 

Treatment. — As above remarked, erysipelas may be more or less 
sthenic or asthenic. Thus we may account for the diverse views and 
results of treatment. It is very common now to treat erysipelas 
with free stimulation. And yet I do not remember ever to have lost 
a case of erysipelas, in which life was not already in serious danger 
from a previous injury, — either in private or hospital practice. Nor 
have I, in more than a very few out of a large number of cases, found 
occasion to give any alcoholic stimulant whatever. 

I have commonly begun the treatment of an attack of the disease 
with a mild saline cathartic, — as a small dose of Epsom salts, or one 
of Rochelle salt or citrate of magnesia. Then blue pill with ipecac, 
if the stomach be good (gr. ^ of the former with gr. J or gr. \ of the 
latter, every three hours) and neutral mixture or liquor ammonia ace- 



PUERPERAL FEVER. 297 

tatis. Asthenic cases appear to grain by the free use of iron, — twenty 
drops of the tincture of the chloride every three hours. 

Locally, mild emollient applications are the best, except as cordons 
sanit aires, or lines of demarcation. At the very start, lard, tallow, 
or cold cream may almost " put out the fire" at once. Mucilage of 
slippery elm bark, or of flaxseed, and diluted lead-water, are all that 
my experience justifies for application to the eruption itself. 1 I would 
not try to suppress it. I think I have seen one death result in the prac- 
tice of another physician from the attempt to do this with nitrate of 
silver over a large surface ; cerebral congestion and coma took place. 

To head off the eruption is perhaps only worth while when, from 
the face, it is spreading to the head. Tincture of iodine, or strong 
solution of nitrate of silver may, for this purpose, be painted in a line 
of half an inch in width ; or a narrow strip of fly blister may be put 
on. 

When, in traumatic erysipelas, a limb is greatly swollen and in- 
flamed, threatening destruction of the subcutaneous tissues, long in- 
cisions through the integument to relieve pressure and congestion 
may be justifiable. 

A milk diet is usually suitable in this disorder. 

PUERPERAL FEVER. 

In the time succeeding confinement, liability always exists (besides 
the transient " milk fever" about the third day) to metritis, and, more 
often, peritonitis ; also, but with much less frequency, to that asthenic 
febrile affection, to which the designation puerperal fever is best 
given. 

As this belongs rather to obstetric practice, I propose only the 
briefest allusion to it. Beginning with a chill, its symptoms are, 
fever, with an extremely rapid pulse, pain in the abdomen, and tender- 
ness on pressure, or on motion, as in drawing up the knees ; tympanitis, 
often ; and. a day or two later, vomiting, delirium, and a tendency to 
collapse. Death may occur within a week ; and more than half the 
cases are fatal. Sometimes the pain and tenderness of the abdomen 
are slight or temporary only ; the general debility proceeding still to 
the fatal end. 

Autopsy shows in much the larger number of cases the manifest 
lesions of peritonitis ; serum, lymph, with extensive adhesions or pus. 
In a few cases, however, these are absent entirely. Inflammation of 
the uterine veins has been met with. 

In causation, it is observed that nearly all the cases of this disorder 
(distinct from simple peritonitis of the lying-in room) take place in 
towns, or in hospitals, especially those which have surgical as well as 
obstetrical wards. Puerperal fever is many times endemic in such 
localities. Physicians have been beset with it, in some instances, in 
practice, as a " private pestilence ;" every woman attended by one prac- 
titioner, for months together, being attacked by it ; when others have 
none of it. Hence we infer two or three things. 

1 Solution of sulphite of soda has lately been used, with great asserted ad- 
vantage. 



298 ZYMOTIC DISEASES. 






One, that this fever has a material zymotic cause, which may be 
localized. Another, that this materies morbi seems to be conveyable 
by hand from person to person. Although disputed by eminent au- 
thorities, the evidence preponderates in favor of this opinion. Further, 
several morbid poisons appear, in the peculiarly susceptible, quasi- 
traumatic state of the womb and abdomen after delivery, to promote 
the disease. Erysipelas does so, or at least the conditions productive 
of erysipelas ; also, the typhus poison ; perhaps that of smallpox and 
scarlatina, &c. As to erysipelas, it presents a close and striking an- 
alogy with puerperal fever. Thus : — 

Erysipelas is an acute febrile Puerperal fever is an acute fe- 

disease, occurring most often brile disease, most common in 

in surgical hospitals, in which lying-in hospitals, in which a 

a peculiar diffusive inflamma- peculiar diffusive inflammation 

tion is a prominent character- is a prominent characteristic ; 

istic ; the seat of this inflamma- the seat of the inflammation 

tion being the skin and con- being the uterine veins and 

neetive tissue. peritoneum. 

Pathologically, some questions are yet not entirely decided. Is 
puerperal fever a special disease, with one specific morbid material 
cause or virus ; or, is it a cachmmia, which any morbid poison has 
power to produce during the lying-in state ; or, again, is it an ich- 
orrhazmia, from absorption of foul matter from the cavity of the 
uterus by its semi-patulous sinuses ; or, a pywmia from inflammation 
and suppuration of the uterine veins ? 

I am not ready to answer these questions. Perhaps the ichorrhoe- 
mic theory has the most of evidence at present in its favor ; adding 
to that, the hypothesis of " continuous molecular change," alluded to 
already in another place. 

Practically, sanitary measures of precaution are clearly indicated to 
prevent puerperal fever. Lying-in hospitals must be great evils, rather 
than benefits, unless they have the best possible situation, construc- 
tion, and administration. And no such hospital, or ward, should ever 
be under the same roof or in the same inclosure with a surgical ward 
or hospital. Moreover, in private practice, attendance in delivery by 
a physician who is visiting at the time a case of puerperal fever or of 
erysipelas, is at the risk of the patient ; if the danger of conveyance 
of the disease be removable, it is only so by the most careful and 
thorough cleansing and disinfection. The clothes should be changed, 
and the hands washed in strong solution of chlorinated soda, before 
making such a transit from the one patient to the other. Several 
physicians in this city always decline confinement cases under the 
circumstances named. 

The treatment of puerperal fever has often proved unsatisfactory. 
I had intimate knowledge of the experimentation to which it was sub- 
jected in the wards of the Pennsylvania Hospital, by Drs. Meigs and 
Hodge, between 1845 and 1849. Venesection, purging, and mercu- 
rials, &c, were tried amply, and failed most signally. 

Quinine, in tonic doses, with beef-tea, and, if collapse be threatened, 
alcoholic stimulation, has, though far from always successful, had at 
least better results. Leeching the abdomen freely, at the beginning 



CHOLERA. 299 

of the attack, in the least asthenic cases, does important good. After 
the leeches, for a day, warm poultices may be applied ; then, a large 
blister. Sulphites are worth trying in this disease. 

For the personal prophylaxis of puerperal fever, obstetricians of 
authority confirm from experience the reasonable view, that it is of 
great importance to empty the womb, and, if possible, the vagina, 
thoroughly, after child-birth. Good uterine contraction is indispensable 
as a safeguard. Washing out the vagina, within a few hours of de- 
livery, with lime-water or solution of glycerin, may also be recom- 
mended for a similar end. 

CHOLERA. 

Synonyms, — Epidemic, Spasmodic. Malignant, Asiatic, Indian 
Cholera; Cholera Algida ; Cholera Asphyxia. 

Symptoms and Course. — Premonitory diarrhoea, mostly painless 
and watery, occurs in most, but not in all cases. Its duration varies 
from an hour or two to two or three days. The worst epidemics of 
cholera, however, have been marked by some cases of fearful rapidity. 
In India, in a few instances, death has resulted, by collapse, in ten 
minutes. 

Commonly, the diarrhoea increases in frequency and copiousness, 
and. in a few hours, vomiting commences. The discharges are color- 
less or " rice-water" like, and are spirted out with spasmodic force. 
The skin grows cold by degrees, and great debility comes on ; with 
cramps, in all the limbs, usually. 

If not checked, collapse arrives ; with intense thirst, oppression in 
breathing, loss of voice, disappearance of the pulse, suppression of 
urine, cold, blue, and shrunken skin, sometimes bathed in sweat, and, 
at last, cold breath ; ending in death. This occurs, on the average, 
in about eighteen hours. 

When reaction takes place, recovery may immediately become com- 
plete ; or, a low fever may supervene. The termination of this may 
be in death, within a few days, or recovery in a week or two. 

Appearances after Death. — Rigidity occurs soon ; sometimes in 
less than an hour; generally within two hours. Startling movements of 
the corpse have been several times noticed ; as of a patient, dead with 
cholera, slowly lifting both hands over the chest and joining them ; 
opening the eyes and rolling them downward, etc. Increased heat of 
the body, cold during the attack, has been sometimes observed after 
death. Internally, several of the great organs, the brain, spleen, and 
kidneys, at least, are commonly gorged with blood. So are the right 
cavities of the heart ; but the left side of the heart empty or with but 
little blood, and firmly contracted. The lungs are almost bloodless. 
The liver varies in appearance ; but the gall-bladder is almost always 
full of bile. The urinary bladder is, constantly, greatly contracted. 
The stomach and intestinal canal are congested and swollen ; the late 
Prof. Horner observed the frequent throwing off of the M epithelial" 

1 See, for the fuller statement of the author's views upon this disease, his 
Essay, entitled " Cholera : Facts and Conclusions as to its Nature, Prevention, 
and Treatment." 



300 ZYMOTIC DISEASES. 

lining of the canal ; Bbhm, of Germany, confirmed this ; Drs. Parkes, 
Gull, and Lindsay assert it to be a 'post-mortem occurrence. 1 The 
intestinal glands are found considerably enlarged. The blood has been 
carefully examined by Drs. Garrod, Schmidt of Dorpat, and others. 2 
Its water and salts transude into the alimentary canal, with some of 
the albumen and fibrin ; also the contents of the blood-cells transude 
into the serum. The blood drawn from a vein during life is (as I have 
seen it) dark, thick, and tarry, scarcely capable of flowing. Schmidt 
found the amount of oxygen in the blood-corpuscles less than half the 
normal proportion. The blood is acid sometimes in cholera ; the re- 
verse of its natural reaction. 

The ganglia of the " sympathetic" system have been often examined, 
and are frequently changed in appearance ; congested, softened, altered 
in color; but no special change has been shown to belong to them in 
cholera. 

Diagnosis. — Common cholera morbus alone {absurd name, hybrid 
of Latin and Greek ; as absurd also is cholera, from the Greek for 
bile, a cognomen for a disease in which the excreta are remarkable for 
the absence of bile), when severe, resembles epidemic cholera so much 
as to be easily mistaken for it. The collapsed stage of the one, pre- 
ceding death, is almost identical in appearance with the collapse of 
the other. But cholera morbus is caused by some irritant of the 
stomach and bowels, and is clearly an affection of those organs, not a 
toxaemia or systemic disorder ; it is sporadic, not epidemic ; in it the 
discharges are always bilious at first, and mostly so to the last ; col- 
lapse in any degree is rare, and death, under judicious treatment, 
very uncommon. In all these things, it differs greatly from Asiatic 
cholera. 

History. — Putting aside some possible resemblance to this disease 
in descriptions of Aretaeus and one or two other ancient authors, pro- 
bably the epidemic in France of 1545, " trousse-galant" came more 
near to it. The earliest distinct account of cholera was that given 
by Bontius, a Dutch physician of Batavia, 1629. Willis (1684), 
Morton (1692), and others, described epidemic fluxes and "dysen- 
teries" in England in such terms as strongly to remind us of cholera; 
and so did Degner of Nymwegen, in the Netherlands (1736), and 
Morgagni in Italy, in 1733. Some British physicians (Greenhow, 
Aitken) now believe that cholera may have repeatedly visited Eng- 
land. It appears to me more probable, however, that this opinion is 
due to an overestimate of the resemblance between the autumnal 
cholera morbus of Great Britain (like our own) and the pestilential 
disease. 

Certainly cholera must have existed in India for an indefinite time. 
From 1781-2 dates its extended prevalence, in a most destructive 
form ; at Calcutta, in Madras, on the Coromandel coast, and in Ceylon. 

In August, 1817, Jessore was the birth-place of the first great 
migratory epidemic. Shortly after, in Calcutta, 36,000 were attacked 
in three months. At many military stations, it was very severe. 
Roads were covered with dead and dying, unable to reach their 

1 Edinburgh Med. and Surg. Journal, Jan. 1855. 
3 Brit, and For. Medico-Chirurg. Rev., July, 1854. 



CHOLERA. 301 

homes. In November, the grand army of the Marquis of Hastings 
was devastated by it. Of 90.000 men, in twelve days 9000 had died. 
On marching the army across a river to dry and elevated ground, the 
commander was relieved of this otherwise invincible enemy. 

In 1818, the Birman empire was invaded by cholera ; and there and 
elsewhere in Asia, its ravages were fearful. In 1819, 150,000 died of 
it in the Presidency of Bombay. It also reached Mauritius, 20° S. 
latitude, three thousand miles from any place before visited by it. 
The Island of Bourbon was visited in 1820 ; as well as the Philippine 
Islands. In 1821, Borneo and Java were affected ; and a large Persian 
army was repulsed by it from before Bagdad, without a battle. In 
1822 its limits were much narrowed, and its destructiveness abated. 

India almost escaped in 1823, but China was ravaged by it ; and it 
extended northwestward, in that year, to Orenbourg. on the Ural, near 
the borders of Europe and Asia. In 1826 it passed the great wall of 
China in its northward progress ; but almost left Western Asia. It 
reappeared in Persia in 1829. 

Orenbourg was revisited in that year, and the epidemic there lasted 
from August to near the end of February. This city had a population 
at that time of 11,000, of whom 6000 were soldiers. Those first 
affected had no communication whatever with any infected place. 

1831 saw the cholera in the north of Europe, as far as Archangel, 
near the Arctic Ocean, more than 64° N. latitude. It reached 
Warsaw in April, during an insurrection, and was very fatal. Hun- 
gary suffered from May to September; losing 100,000 of its population. 
In June, St. Petersburg, and in September, Moscow, were reached by 
the pestilence. Berlin had it also for three months and a half, begin- 
ning in August. Mecca was attacked during the visitation of throngs 
of pilgrims, in May; of 50.000, as many as 20,000 are said to have 
perished. In this year, while Hungary was infected, the Austrians 
surrounded Vienna by a double cordon militaire ; but in vain. The 
disease began there in August and continued for three months. The 
southern provinces of Austria and the Rhineland were exempt. Con- 
stantinople was affected by it, but not with very great severity. The 
Turkish government, that year, maintained no quarantine. Cairo 
suffered dreadfully in 1830-31 ; and so did Smyrna. 

Attacking Hamburg on the 11th of October, 1831, it was officially 
announced at Sunderland, England, October 26th. It had occurred 
in several cases in England months before. Three or four weeks later 
it appeared at Newcastle ; and in December, at Haddington, a Scot- 
tish town on the Tyne. 

Edinburgh and Glasgow first had cholera in January, 1832 ; London 
in February ; Dublin and Paris in March. London then suffered but 
moderately ; Paris terribly — especially in April and May ; 20,000 deaths. 

On the 8th of June, it first invaded our continent, at Quebec ; and 
within a week, at Montreal. In the same month it was in New York 
and Albany. Philadelphia had its first cases in July. Between the 
1st of July and the 18th of August, New York had reported 5337 
cases, with 2068 deaths. That city lost 3513 in all. 1 From the 27th 

1 Dr. A. Clark, Lect. on Cholera. In 1834, New York lost 971; in 1849, 
5071 ; in 1854, 2509. 
26 



302 ZYMOTIC DISEASES. 

of July to August 18th, Philadelphia had 1610 cases, with 615 deaths. 
Boston and Baltimore were moderately affected in August. 

Detroit, Buffalo, Elizabeth City in North Carolina, Wilmington and 
Newcastle, Delaware, Norfolk and Portsmouth, Virginia, and New 
Orleans were the principal of more than fifty towns in the United 
States reached by cholera in 1832. It had entered twelve different 
States before September. 

Havana and Mexico were attacked in the spring and summer of 

1833. The City of Mexico, notwithstanding its great elevation above 
the sea, did not escape. 

Portugal was also first visited in that year; Spain but slightly until 

1834. Northern Italy was affected in the autumn of the same year. 
In 1835, Alexandria and Malta ; in 1836, Rome, Naples, Egypt, and 
Central America especially suffered. North Germany, South France, 
Borne, Naples, Sicily, Malta, Egypt, and Syria, in 1837. After that 
cholera disappeared from Europe and America for nearly ten years. 
It still existed, in variable violence and extent, in India. 

In 1847, it ravaged a Russian army west of the Caucasus ; and in 
September returned to Moscow. In 1841, Turkey, Russia, Austria, 
Prussia, Belgium, Holland, Great Britain, and France (though not 
Paris) were successively attacked. Then the cholera showed its 
power to traverse the sea without human aid or agency, by attacking 
two emigrant ships, a thousand miles apart, one sixteen and the other 
twenty-seven days out from Havre, when no cholera was prevailing at 
the port. 1 The cholera-cloud itself also reached New Orleans about the 
same time, and progressed up the valley of the Mississippi. New 
York was not affected by the visit of the infected ship ; the disease 
not occurring again there until May, 1849. 

Paris was reached by it in February of that year, but suffered the 
worst in June. Lyons now had it for the first time. Tunis and Al- 
giers were visited toward the end of the year. 

In January, 1849, after Memphis, St. Louis, Missouri, was attacked. 
Chicago, Buffalo, and other towns on the lakes, in May. New York 
and Philadelphia in the same month. Baltimore had this year only a 
local epidemic, in July, in the Almshouse ; the restriction of which 
to one side of the building was very remarkable. As in 1832, the 
mortality in Philadelphia was much less for the population than in 
New York : 1022 deaths occurred in our city ; New York had a mor- 
tality 450 per cent, greater. 2 Canada was reached this time from the 
westward. 

In 1848-9, the number of deaths from cholera in England and 
Wales was over fifty-four thousand (54,398) ; in 1832-3, nearly thirty- 
one thousand (30,924). In London, 3 probably owing to greater at- 
tention to sanitary means, the mortality was two-fifths less the second 
time than the first. Some parts of southern Rhineland were visited 
in 1849 ; especially the filthy city of Cologne. 

Cholera lingered in various places almost sporadically, in Europe 
and America, from 1850 to 1854. Canada and the far West (Indiana 

1 Report on Cholera in the United States, by Dr. James Wynne ; and Dr. 
Gavin Milroy, Brit, and For. Medico-Chirurg. Review, Oct. 1865, p. 444. 

2 Dr. J. II. Griscom, Medical Record, March 15, 1866, p. 35. 

3 London had 13,098 deaths from cholera in 1849 j in 1854, about 10,000. 



CHOLERA. 303 

also had cases every year) suffered the most iu this way, on our con- 
tinent. In the West, emigrants' camps and military stations seemed 
especially to furnish its required local conditions. 

In 1853, Persia had it severely ; also some parts of Northern. Cen- 
tral, and Southern Europe (Copenhagen, Hamburg, Berlin, Piedmont, 
Lyons, Paris, and Southern Portugal). Before the end of the year 
it was again in New York, New Orleans, and the West Indies. Mexico 
had been visited in the spring, and through the summer. 

1854 was still more a cholera year in Europe and in this country. 
Scarcely any European state or kingdom was exempt. The French, 
English, and Russian troops suffered from it much in the Crimea. 
Greece, Italy, Germany, France, Spain, Portugal, in short, all Europe 
was traversed by it : 150,000 died of it in France alone ; in England 
and Wales about 20,000. Newfoundland, on our side of the ocean, 
was reached for the first time in 1854. This was the year of the epi- 
demic at Columbia, Lancaster County, in this State ; so remarkable 
for the absence of some of the usual promotive conditions of cholera. 
Oar great cities, however, did not suffer nearly so much as in 1849. 

In 1855, the disease was widely spread in Europe, though not very 
malignant except near the seat of war, before Sebastopol. Egypt 
and Palestine had it also. In Switzerland, which had been slightly 
touched before, Basle, Geneva. Zurich, and other places now suffered 
by it. The next year, 1856, still did not witness its withdrawal from 
Europe. 

Since that period, until 1865, I have no means at hand for tracing 
the movements of epidemic cholera. Dr. Garvin Milroy says that the 
countries hitherto exempted have been as follows : Australia, New 
Zealand, and other islands in the Pacific ; the Cape of Good Hope 
and adjoining settlements ; the coast of Africa from the Cape as far 
northward as the Gambia, and including the islands of St. Helena and^~ 
Ascension ; the Azores, Bermuda, Iceland. Faroe islands, and also 
the Orkney and Shetland ; the southern half of the eastern coast of 
South America, from the Rio Plata inclusive, Cape Horn, and the 
whole of the western coast of that continent, from the Cape and along 
the shores of Chili and Peru to Panama. 

In 1865, every one was familiar with the accounts of cholera in 
Arabia and Egypt in the spring, at Constantinople in July, 1 and 
afterward in several parts of Europe, extending, though with but 
moderate violence, as far as England. While its vast migrations seem 
to be as capricious or incalculable as the flight of locusts, two local 
causes contributed at least to its severity in Mecca and on the Nile. 
These were the crowds of religious pilgrims at the former place, in the 
spring, and, in Egypt, the insalubrious circumstances attending the 
operatioos at the new Suez Canal. In both, "crowd-poison" was in- 
tensified to the greatest degree; so that the pest-cause might well find 
there strength for the renewal of its flight onward to the northwest. 
In Paris, in 1865, 6383 deaths occurred during the late visitation. 

I take from Dr. Brigham's treatise (published in 1832) the following 
table, of the deaths from cholera in 1832, and their proportion to 
population : — 

1 The first case occurred in that city on the 28th of June. 



304 



ZYMOTIC DISEASES. 



Population. 


Deaths. 


Equal to 


350,000 


4,690 


lin 74 


360,000 


4,757 


1 " 74 


300.000 


11,896 


1 " 159 


340,000 


1,401 


1 " 242 


100,000 


446 


1 " 224 


1,500,000 


1,223 


1 " 1,228 


150,000 


72 


1 " 2,033 


180,000 


395 


1 " 455 


8,750,000 


188,000 


1 " 46 


800,000 


20,000 


1 " 40 


25,000 


1,250 


1 " 20 


22,000 


1,790 


1 " 12 


200,000 


2,000 


1 " 100 


24,000 


311 


1 " 77 



Moscow . 
Petersburg 
Vienna . 
Berlin 
Hamburg 
London . 
Edinburgh 
Glasgow . 
Hungary 
Paris 
Montreal 
Quebec . 
New York 
Albany . 

Supposing the population of Philadelphia to have been at that time 
150,000, this, with a little over 600 deaths, would give a proportion 
for our city of 1 in 250 of the inhabitants. In 1849 the ratio was 
considerably less.' 

It is an important fact in the history of cholera, that before, during, 
and after the epidemic has visited a place, many cases, greatly ex- 
ceeding in number those of typical cholera, occur, of diarrhoea, some- 
times also with vomiting, not violent, yielding easily to treatment. 
To these the name of cholerine is often given. 2 ^ 

Nature of Cholera. — Without discussing opinions at length, it 
may be asserted that cholera is not at all, like our ordinary cholera 
morbus, a disorder simply of the stomach and bowels. Being clearly 
an acute systemic affection, changes in the blood are proved to occur 
in it, and may well be believed to be primary ; that is, that the morbid 
cause acts through the blood. But this is not all. 

Cullen placed cholera, in his nosology, in the class neuroses, order 
spasmi. Many medical observers (Binaghi, Loder, Orton, Delpech, 
Lizars, Coste, Favell, C. W. Bell, Greenhow, G. Johnson, etc.) con- 
sider its principal effects to be referable to disturbed innervation, in- 
volving chiefly the ganglionic centres of organic life. Dr. Charles D. 
Meigs, years ago, graphically called the attack the " cholera squeeze." 
Yelpeau, of Paris, lately repeats this, "le mal vous tortille." There, 
I think, is the pathology of cholera, in one word. As Dr. O. W. Bell 
says, it is not an adynamic, but a dynamic, or sthenic, collapse. 

The heart, its left side at least, is, after death, contracted. The 
pulmonary artery and its branches are narrowed, making the lungs 
pale and anaemic. The gall-bladder is full of bile, but the duct is 
spasmodically closed, and detains it there. The urinary bladder is 
shrunken to half its size or less. The bloodvessels of the whole 



1 Moreau de Jonnes estimates the number attached as, in France, 1 in 300 
of the population ; Russia, 1 in 20 ; Austria, 1 in 30; Prussia, 1 in 100 ; Po- 
land, 1 in 32 ; Belgium, 1 in 120 ; Great Britain and Ireland, 1 in 131; Hol- 
land, 1 in 144 ; Germany, 1 in 700. 

2 The coincidence or anticipation of cholera by epidemic influenza and the 
potato blight, has been several times noticed. But there is, clearly, no uni- 
formity in any such association. 



CHOLERA. 305 

alimentary canal press rigidly upon their contained fluid, and force its 
serum out into the stomach and bowels ; whence it is, by spasmodic 
ejections, thrown out. The very skin is, by its involuntary muscular 
fibres, as well as by vascular constriction everywhere, drawn tightly 
and closely upon the body. The voluntary muscles suffer with cramps. 
All is cramp, cramp, within and without. The brain is almost in 
anaesthesia during the collapse — no delirium, but apathy — as from 
cerebral anaemia. The blood, so compressed, grows thick as tar — it 
scarcely flows, is not aerated, and cyanosis follows ; — it is detained in 
the capillary and venous networks of the interior organs, in which 
congestion is found after death. 

Cholera is, then, I say, a poison-spasm ; a ganglionic tetanus. 

Causation. — As to this, all cannot yet be known. But it is clear 
that cholera must have a specific, material, migratory cause. I agree 
with Dr. G. B. Wood, Dr. Austin Flint, Dr. Snow of Providence, 
and some foreign authorities, for example. Dr. Southwood Smith, 
" the father of modern sanitary reform," in believing that cholera is 
not personally contagious. 

My theory is as follows : That the cause of cholera is a (yet undis- 
covered) protozoon, or primal organism, of extreme individual minute- 
ness ; which, on entering the human body, affects it as an orgauic 
poison. That the varying quantity or number of these organisms may 
in different cases account (along with individual predispositions and 
exposures) for the unequal violence of different epidemics; as in the 
case of trichiniasis. Choleraic diarrhoea or cholerine, so frequent 
before as well as during and after the prevalence of cholera, may in 
some instances at least be explained by the action upon the alimentary 
canal only, of a minimum quantity of the cause. The dreadful fatality 
of some Indian seasons, is on the same view referred to an extreme 
accumulation of it. 

A most important part of the theory is, further, that which concerns 
•promotive causation. What conditions favor and maintain in life, 
multiplication, and migration, this ens primalis ? 

All the facts answer, as I believe, that animal matter in a state of 
rapid and fold decomposition, putrefaction, along with moderately 
high (not the highest) temperature, and ordinary moisture, will afford 
those conditions ; and that nothing else is required to explain the 
whole history of the propagation and extension of cholera. Nothing, 
I mean, but the admission of the existence of the " protozoon," which 
in ova or in maturity, or both, may fly " on the wings of the wind ;" or 
be conveyed to less distances by water ; and, with these the above- 
named conditions of its vital maintenance, as its food and " habitation." 

It is, in my mind, obvious that this theory will explain all the facts. 
I believe, also, that some well-known facts can be explained by it 
alone. Such are the facts which account, by annual inundations, 
the mortality of the great fairs, the throwing of bodies into the river, 
and the inconceivable filth of the inhabitants, for the persistent resi- 
dence of cholera in the Gangetic delta, while everywhere else it is 
only an occasional visitant. 

In Europe and the United States, as well as in India, influences 
belonging to closely aggregated communities have always been 
observed to displav a power to propagate cholera. It comes most 

26* 



306 ZYMOTIC DISEASES. 

often, stays longest, and is most destructive, in the densest and filth- 
iest cities, and in the worst quarters of those cities. 

Very important testimony exists as to the influence of the drinking 
water of localities. Dr. Snow, of England, asserted the theory that 
this was the almost universal medium of its propagation. This has 
been shown to be quite insufficient. But all such testimony is still 
available in regard to the propagating and extending power of animal 
contamination. Thus, Bethlehem Hospital, supplied by an artesian 
well, had, in 1849, among 400 inmates, no case of cholera. It was 
the only large lunatic hospital in London which escaped ; as it was 
the only one supplied with spring water. In the districts of London 
supplied from the Thames above the entrance of the sewers, the mor- 
tality ranged from 8 to 33 in 10.000 of the inhabitants; in those 
supplied from below the entrance of the sewers, from 28 to 205 of the 
same number. 

In this country, Dr. James Wynne's report 1 affords, upon almost 
every page, matter of exactly the same purport as the above. In St. 
Louis, Louisville, Buffalo, New York, Philadelphia, Boston, etc., 
similar facts were recorded. It is unnecessary to extract them, they 
are now so familiar and so commonly accepted. 

The instances of apparent transmission of cholera by persons, which 
are quite exceptional, even if we admit a hundred or more authentic 
examples, are, as I believe, to be explained on the principle of fomites ; 
of occasional, very rare, carrying of the material cause of the disease, 
the ''germs" of it, in clothing, merchandise, or by the person of a 
human being ; as one might carry skippers on a piece of cheese in his 
pocket, or a paper of flower seeds in his carpet bag. 

All of Pettenkofer's and Thiersch's observations, in regard to sub- 
soil accumulation and transit, and faecal fermentation after discharge, 
range themselves naturally under the one general fact which they 
exemplify, viz., that animal decomposition is the one great promotive 
cause of cholera; to which heat and moisture, etc., are merely adjuncts. 

But, that which suggested first to me this opinion was, the singular 
history of the outbreak at Columbia, Lancaster County, Pennsylvania, 
in September, 1854. Cholera had never visited that town before. It 
is not large or populous, in a rural site, on the Susquehanna, not 
built densely enough to exclude malarial fevers. Why should it have 
cholera at all ? 

Visiting the town, with other physicians of our city, during the 
epidemic, I learned that an exceeding drought had reduced the chan- 
nel of the river to an unusually low ebb, and that, in its bed, a short 
space above the town, a number of carcasses of sheep and other 
animals, thrown from the railroad trains, etc., were putrefying rankly 
in the sun. A reservoir which supplied many of the people with 
drinking water was filled from the river not far from that spot, and 
the wind blew from it directly over the town. The first subsidence 
in the disease, we were afterwards told, attended a decided change in 
the wind. 

At Pittsburg, shortly after the above events, a similar epidemic oc- 
curred. A gentleman on a visit to that locality not many days before 

1 Presented to Parliament, and published in 1852. 



CHOLERA. 307 

the disease broke out, informed me that the same condition of the 
river existed there, with a like abundance of accumulated putrefying 
animal matter, exposed to the sun. 

In Ehode Island, in the autumn of the same year, I was informed 
that the local existence of cholera in a few spots, otherwise very 
healthy, might be traced, in coincidence at least, with a practice not 
uncommon along the shore of the sea or bays, of dragging up fish in 
quantities by nets, and spreading them out to rot for manure. 

Prevention. — Quarantine is urged by many, in this country as well 
as in Europe, to exclude cholera. Is it available ? Will it do any 
good? I say, no. Theoretically, if the views advocated in the pre- 
ceding pages are correct, it falls to the ground of course. But, more 
than that, it never lias succeeded. 

Dr. Alison, of Edinburgh, wrote thus in 1854: — 

" It is a fact that cholera has made its way, not uniformly, but very 
generally, in spite of cordons and quarantine regulations" 

Dr. Gavin Milroy, one of the ablest and most industrious sanitari- 
ans of our time, published, about the same year, an essay with this 
title: " The Cholera not to be Arrested by Quarantine." 

Even Pettenkofer, the leading advocate of the hypothesis that 
cholera is diffused by the influence of the discharges from the bowels, 
has announced his conviction that local sanitary measures are much 
more reliable for its prevention than quarantine. 

Quarantine, if sound in theory even, could not avail, never has 
availed in practice. Its infraction for smuggling and other induce- 
ments, is everywhere constant and notorious ; this cannot be prevented. 
Macaulay (History of England, vol. v. p. 52) states that when a con- 
traband trade was, in the time of William III., carried on between 
France and England on the southeastern coast, u it was a common 
saying among the inhabitants, that if a gallows were set up every 
quarter of a mile along the coast, the trade would still go on briskly." 

One might think the history of blockade-running . during the late 
rebellion in this country, might afford ample illustration and confirma- 
tion of this. Vain, indeed, would be the attempt to close our coast 
against the introduction of cholera, were it as contagious as small- 
pox, or as plague was once imagined to be. 1 

The evils of quarantine are great, almost incalculable. Sir John 
Bowring, speaking in the House of Commons in 1841, gave it as his 
belief that the losses from quarantine in the Mediterranean alone 
were not less than two or three millions sterling a year. 

But what if, instead of preserving, quarantine actually involves, 
often, sacrifice of life? No doubt this has many times occurred. 
With yellow fever, the quarantine epidemic in New York harbor, a 
few years ago. exemplified this. In various quarters reports of travel- 
lers show the miseries and dangers of the lazaretto, and of the con- 
finement on the vessel detained. 

What more do we need to show this than the very recent instance 
of the steamer England, at Halifax ? Forty passengers, one account 
says fifty (out of 1202), died on this vessel during the voyage. She 

1 The Governor of Eupatoria is said to have wished the British and French 
troops to undergo quarantine, at the opening of the Crimean war ! 



308 ZYMOTIC DISEASES. 






was prohibited from entering port ; all were detained on board, and, 
by April 14th, 1866, 130 more deaths occurred ! In all, 159 died while 
in quarantine. If the twelve hundred passengers had been landed and 
scattered, I, for one, doubt the occurrence of the disease in a dozen 
of their number; especially as it was reported as altogether confined 
to the steerage. 

Were such measures sure to preserve from the epidemic the whole 
people of our continent, a hecatomb like this might find excuse. In 
the face of facts, I regard it as a barbarity. Pelissier, in Algiers, was 
thought a monster, for suffocating a band of guerrillas in a cave ; but 
what is this case of the England more like, except in motive ? It is 
closing up hundreds of people for death ; as though one might lock 
the doors, and bar the windows, against all escape of a thousand 
people from a burning church ; such as that of which we read so har- 
rowing an account, some time back, in South America. 

But it will be said or asked, would you abolish all quarantine — 
abandon all inspection of ships whatever? No ; I would not. But I 
would abandon altogether the whole theory of quarantine, as against 
cholera most particularly. 

Ships should be inspected on approaching ports, because they may 
have unsanitary conditions intensified in them, on a scale sufficiently 
large to be important. This is, or should be, a part of sanitary police. 
Nor should it (and here is a great point of difference) include any 
restriction of persons ; at the most, longer than enough for cleansing 
of the body and of the clothing, and purification of merchandise, by 
fresh air, and possibly by some disinfecting process in certain cases. 

I insist that Sanitary Police includes the sum total of available 
measures for the prevention of cholera in any place. 

On this ground, the measures required are obvious, and familiar. 
The thorough and frequent cleansing of all streets, alleys, courts, 
wharves, and vessels, private and public buildings, and empty lots ; 
the abatement of all nuisances ; daily removal of offal ; efficient sewer- 
age ; and conservancy, i. e., the cleansing, ventilatioft, and disinfection 
of cess-pools and water-closets. Among all signs of danger of the 
location of cholera, none is more significant than the privy odor. Let 
it be everywhere annihilated. Lime, charcoal, dry earth, chloride of 
lime, Labarraque's chloride of soda, liquid coal tar, chloride of zinc, 
and sulphate of iron are the most available of disinfectants. 

The fresh white-washing of cellars is useful ; thorough ventilation 
and d^ing of them and of all parts of habitations, still more so. 
Chloride of lime may be placed, in a saucer, in any suspected room or 
other locality in a house. The same, in the solid form, or solution of 
green vitriol, may be thrown daily into a foul privy; and, during 
cholera time, especially in the case of patients with the disease, every 
water-closet and vessel used may and should be disinfected constantly, 
by a dilute solution of chloride of zinc, chloride of soda, permanganate 
of potassa, or carbolic acid. The immediate removal of all discharges 
from the sick-room, their disinfection and transportation to the safest 
possible place of elimination, ought to be imperatively maintained. 
All foul clothing must be promptly washed, or, if very bad, disinfected 
or burned. 



CHOLERA. 309 

These precautions have been proved to be capable of essentially 
limiting and mitigating the prevalence of epidemics. 

Personal Prevention. — One principle will suffice here : to keep the 
system at par; neither above its level of excitement, nor below that 
of its due strength. 

For this, regularity of life is required, in work. diet, mental move- 
ments, and all indulgences. The popular errors most common are. 
one, to suppose that living on rice or rice-water, avoiding fruits or 
vegetables, etc.. will be preventive; another, to think constant alco- 
holic stimulation beneficial for that end. Both are certainly wrong. 

In 1832 and 1849. the late Dr. Joseph Hartshorne, my father, then 
in very large practice, allowed in his family all its usual variety of 
food : boiled corn, peaches, watermelons, cantelopes. etc., everything 
but cucumbers ; and no cholera resulted from the liberty. My own 
subsequent experience justifies the practice. Of course care is always 
needed as to quality and quantity. 

Of all those most likely to die when attacked by this disease, the 
drunkard stands first, according to all records. Xor is he one whit 
less apt to be attacked than others. Temperance, in all things, is 
essential to safety during epidemics of every kind. 

Treatment. — To discuss all the modes of management proposed 
for cholera, would occupy too much space. I shall merely enumerate 
those which have attracted the most attention ; and then give my view 
as to what is so well sustained as to be worthy of further trial and 
some confidence. 

1. Bleeding. — This was largely practised in India, in 1818-1825, 
by Corbyn. Scot, Annesley. and others. Without entering upon any 
argument about it, I will simply say. that (as Dr. Brigham's quota- 
tions show) as many positive facts have been asserted on behalf of the 
success of blood-letting as of any other remedy in cholera. 1 My father 
bled in several cases in 1632. and had confidence in the treatment, as 
" the most effectual antispasmodic.'' In 1849 I bled in one case (a 
boy of twelve years of age), in incipient collapse. The blood at first 
was thick and black as tar ; in a few minutes it flowed more freely. 
and the patient recovered. I confess that the only thing which makes 
it unlikely that I will ever try or advise the repetition of this practice 
is. the want of courage to stem the overwhelming tide of professional 
and popular opposition now existing against it. In this timidity I 
may be wrong : if so. another generation may afford the demonstration 
of what is right, in such a way that no one can gainsay it. 

2. Calomel. — This. too. was an old East Indian remedy. Suggested 
by the almost universal absence of bile in the discharges, which was 
thought to indicate the need of stimulation of the torpid liver, it has 
been more largely given than any other medicine in cholera. 

Unhesitatingly. I hold the opinion that calomel is of no earthly use 
in cholera. The argument in its favor, from the absence of bile in the 
stools, is rebutted by the fact of its abundance in the gall-bladder ; 

1 In 1861, Surgeon G. R. Playfair, fit Agra, India, found venesection to 
about 8 ounces, followed by stimulants (especially chloroform) the most success- 
ful treatment. He reports more than 77 per cent, cured, of genuine cholera. 
— Edin. Med. Journal } Sept. 1866, p. 275. 



310 ZYMOTIC DISEASES, 






while the clinical experience quoted, for its success is accounted for 
by the addition to it, almost always, of opium, in the prescription. 
Nor is the amount of success with it, even then, great. Such is Dr. 
Gull's conclusion, based upon the examination of a great mass of evi- 
dence, given in his report. 1 

Dr. Ayre, a British practitioner of some note, gave prominence to 
a modification of the old calomel treatment (in which twenty grains 
were sometimes given at once), by prescribing a grain of calomel 
every five minutes during the attack. 

3. Saline Treatment. — Dr. Stevens, of Jamaica, proposed this, 
upon the view that the main pathological element in cholera was the 
loss of salts from the blood in the discharges. After the general fail- 
ure of saline solutions (of common salt, carbonate and phosphate of 
soda, etc.), given by the mouth, had been conceded, Dr. Mackintosh, 
of Edinburgh, and others, tried the method of injection into the veins 
(half an ounce of common salt, and four scruples of sesquicarbonate 
of soda, dissolved in ten pints of water, at 105° to 120° Fahrenheit). 
Under this plan, resorted to during collapse, of 156 patients in Dr. 
Mackintosh's hands, only 25 recovered. Remarkable improvement, 
almost like a resurrection, appeared in several, who afterwards fell 
again into collapse, and died. The suggestion has been recently made, 
that it may have been the temperature of the injected liquid which 
produced the benefit, so promising and yet transient. 

4. Eliminative Treatment. — Dr. George Johnson, of London, has 
urged this with especial vigor. The castor-oil medication of cholera 
owes its trial to him. Some recent lectures of his on the pathology 
and treatment of the disorder give a full and very intelligent exposi- 
tion of his views. A prominent idea with him is, that the general 
collapse is due especially to anaemia of the lungs, owing to spasmodic 
contraction of the pulmonary artery and its branches. I regard this 
as only a part of the universal arterial (and other) involuntary muscu- 
lar spasm, belonging to what I have called the ganglionic tetanus of 
the collapse. But the essential feature of Dr. Johnson's pathology is 
the opinion that, the disease being toxaemic, a morbid poison exists 
which must be eliminated from the blood ; and that the discharges are 
the media of this elimination. Therefore, the vomiting and diarrhoea 
are salutary or relieving ; and ought to be rather encouraged than 
checked. He goes even so far as to repudiate the commonly accepted t- 
belief, that " premonitory diarrhoea" or " cholerine" ought to be 
checked ; considering it a fallacy to assert that those who are relieved 
of such symptoms by mild treatment were really, or would have been, 
cases of cholera at all. 

I am entirely unable, from observation or reflection, to assent to 
these views. They have very few advocates or supporters, besides the 
distinguished physician whose name and ability command for them at 
present careful consideration. It is true that patients have died of 
cholera without vomiting or purging. I saw in 1849 a woman in col- 
lapse (from which she recovered) for several hours without either ; 
and many such cases are on record ; though, in some, after death, the 
intestines have been found to be distended with the rice-water liquid. 

1 Report, etc., of Drs. Baly and Gull, already cited. 



CHOLERA. 311 

But the checking of the discharges is almost always the sign of 
improvement and recovery of the patient. And we cannot, on Dr. 
Johnson's dictum, set aside or quash all the accumulated evidence, in 
Europe and in this country, 1 which shows that it is desirable and im- 
portant to check all watery diarrhoeas in cholera times — such fluxes 
having been proved to be often premonitory of cholera attacks. 

5. Ice to the Spine. — Dr. John Chapman's ice-bags threaten to 
become the "pathy" or therapy of the day, with those who are zealous 
and venturesome in experimental practice. Upon reasons of a physio- 
logical nature, not appropriate for discussion here, I disbelieve alto- 
gether in the theory of his therapeutics. In his pamphlet upon 
" Diarrhoea and Cholera," lately published, he gives but one case of 
the latter disease, and does not say whether the patient recovered or 
died. 

As ice is so useful when internally given in cholera, it may be safe 
and beneficial when applied to the spine. Not having seen it tried. I 
am not prepared to deny the possibility. It is one of the experiments 
to consider, in so desperate a disease. But, if it should hereafter prove 
useful, I should explain that result quite otherwise than Dr. Chapman 
has done, in part at least. 

6. Sulphuric Acid. — Dr. Cox, of England, afterward Mr. Buxton 
and Dr. Fuller, and recently Dr. Jules Worms, of Paris, have espe- 
cially recommended dilute sulphuric acid in all stages of cholera. 
Many others especially report well of its action in the premonitory 
diarrhoea. Such an action would comport perfectly with the view I 
have taken of the organic nature of the poison of cholera ; sulphuric 
acid being so potent a destroyer of everything organic, except such 
mirabilia as the Acarus Crossii. 

Dr. Worms' treatment (based on the results in 238 cases of cholera, 
and 150 of cholerine, in 1865) is as follows : For prodromic diarrhoea, 
he makes a " mineral lemonade," of about half a drachm of concen- 
trated sulphuric acid to a pint or more of sweetened decoction of salep 
(arrowroot would do as well). The patient is to take of this every hour 
a wineglassful, till relieved. 

For confirmed cholera, the patient being kept A complete repose, 
there is administered every half hour a glass of a similar lemonade, of 
the strength (about) of a drachm to the pint ; ice and wine also being 
allowed ad libitum. 

7. Opium in large doses. — This practice had once many advocates ; 
now they are few. Prof. Austin Flint, of New York, is one of them ; 
at least morphia is advised by him, in full dose, repeated if required. 
A great deal of evidence of the insufficiency of such a plan has been 
published ; although it is not worse than several other methods. Let- 
ting alone would probably be better. The secondary fever is apt to 
be more severe and more often fatal after treatment of the attack by 
large doses either of opiates or stimulants. Large quantities of brandy 
(I add, by the way) have been often used, with no good results. 

Statistics are given, as follows, of the results of some of the most 
common modes of practice in cholera, by practitioners in Great 

1 See Lectures on Cholera, by Prof. A. Clark, of New York ; Report to the 
Royal College of Physicians, 1854 ; also, Madin, Briquet and Mignot, etc. 



312 



ZYMOTIC DISEASES. 



Britain, as reported to the " Treatment Committee of the Medical 
Council of the Board of Health," 1854-55. 
Taking all grades of the disease, the deaths were — 



With Eliminants 
Stimulants 
Calomel and Opium 
Chalk and Opium 

Of collapsed cases, the mortality was — 



With Calomel and Opium . 

Larger doses of Calomel 

Salines 

Chalk and Opium 

Calomel, small doses 

Castor Oil. 

Sulphuric Acid . 



Per Cent. 
. 71.7 
, 54.0 
. 36.2 
. 20.3 



Per Cent. 
59.2 
60.9 
62.9 
63.2 
73.9 
77.6 
78.9 



Much is uncertain, obviously, in such statistics, without farther 
account of dosage, circumstances, etc. But this seems to follow ; that 
neither treatment has much to boast of success. 

8. Treatment by antispasmodics and mild stimulants, in small 
doses at short intervals ; with ice, and external frictions, etc.— 
In 1849, my first two cases of cholera were fatal ; although assidu- 
ously watched, each for a day and a night. The third, I saw with the 
late Dr. Wm. E. Horner, Professor of Anatomy in the University of 
Pennsylvania. I left the treatment to him. He sat down by the bed- 
side of the patient — a man, blue, cold, and with a scarcely perceptible 
pulse, copiously vomited and purged, with rice-water. Having ordered 
ice, 1 Dr. Horner took from his pocket a vial containing a mixture of 
chloroform, oil of camphor, and laudanum ; which he gave in sweetened 
ice-water, in small doses, every five minutes by the watch. Each dose 
was followed by a pi^ce of ice. 

Soon the vomiting diminished, afterward the diarrhoea, and in an 
hour and a half the veins on the back of the hand began to fill up, 
and the blood to return in them more rapidly after pressure. Dimi- 
nishing the frequency of the doses, we left him, an hour later, evi- 
dently convalescent. When I saw him after several hours again, he 
was sitting up in bed, at ease, and so changed, that I doubted at first 
his identity. No secondary fever followed ; he was cured. 

Naturally, I repeated this treatment in all my subsequent cases, 
some of which were of extreme severity ; and with gratifying success. 
The memorandum book of the number of these cases has, to my 
present regret, been mislaid. After the treatment of Prof. Horner 
had been adopted, however, I saw no death, except in the instance of 
a drunkard, two or three hours in collapse before any medical treat- 
ment began. 

Should I be attacked with cholera, such is the treatment I desire. 



Ice was used, and lauded, in cholera, by the celebrated Broussais, in 1832. 



CHOLERA. 313 

Conscientiously I believe" that nothing else will afford a better chance 
of recovery. I merely altered Prof. Horner's mixture to a tincture, 
for better preservation ; adding some minor adjuvants. This recipe 
will be given directly. Frictions and sinapisms may also be added. 
The great merits of this plan are its antispasmodic nature, and the 
administering of small doses at very short intervals. This is emi- 
nently demanded in cholera. Phthisis may be a complaint of years ; 
hooping-cough, of months ; typhus, of weeks ; pneumonia, of days ; 
but cholera must be numbered by its hours, half hours, or even mi- 
nutes. 

Having reached, then, this conclusion, I may add, that a rationale 
for such a treatment is discernible. I only follow many good authori- 
ties in the opinion that cholera is, symptomatically and pathologically, 
a poison-spasm, or tetanus of the ganglionic system. Taken early, 
that condition may be prevented, by mild opiates and stimulants, in 
the premonitory stage. Later, while any medicines will act. these 
will do the most. What is needed in confirmation of this explana- 
tion, more, than is given by the action of quinine in preventing an 
anticipated chill, or, of the same, in full quininization, curing the 
paroxysmal disease (a toxsemic neurosis) of intermittent ? An anta- 
gonistic influence against that which so perturbs innervation through- 
out the body; such is the whole definition that we can give of the 
remedial power shown in either case. 

Let me be more specific in reference to treatment. Premonitory 
diarrhoea is very generally admitted to be present in a majority of 
cases of cholera. 1 In the East Indies, many writers, of different 
dates (Lawrie, 1832. Stewart Clark, 1864, etc.), assert such a stage 
to be an exception instead of the rule. But, in India, they have a 
premonitory or incipient stage of another kind ; characterized by great 
languor or depression, with restlessness, and sometimes ringing in the 
ears, occurring mostly in the night. Stewart Clark states 2 that, in 
this stage, a mild opiate ("with a little calomel or blue pill"), with a 
cup of warm tea or a small dose of a diffusible stimulant, as a few 
grains of carbonate of ammonia, or a little weak warm brandy and 
water, will arrest the attack in a great portion of cases otherwise to 
become serious. 

Such symptoms, as well as diarrhoea, should be noticed here, during 
a cholera epidemic ; and I believe the same treatment will meet either. 
Rest, warmth, and mild, composing, but gently stimulating draughts ; 
paregoric, aromatic spirit of ammonia, tincture of ginger, lavender, 
etc., with a mustard-plaster over the abdomen, and a hot mustard foot- 
bath if coldness of the body increase, or vomiting begin ; such are 
safe, and I believe will be efficient remedies. The above may be called 
the first or prodromic stage. 3 

The next has been well called, by Prof. A. Clark, the rice-water 
stage. For that, the treatment I have described as given to me by 

1 Barraut asserts fixed contraction of the pupil to be the first prodromic sign ; 
M. Worms makes the same statement in regard to albuminuria. 

2 Hygiene of the Army in India, p. 12. 

3 The recently published experience of Dr. Hamlin, in Constantinople, con- 
firms the importance of the above early treatment. 

27 



314 ZYMOTIC DISEASES. 

Prof. Horner is particularly adapted. My recipe, based upon his, is 
as follows : — 

R. — Chloroform, et 
Tinct. Opii et 
Sp. Camph. et 

Sp. Ammon. Aromat. aa fgjss ; 
Creasot. gtt. iij ; 
01. Cinnamom. gtt. viij ; 
Sp. Yin. Gall. f^ij. — M. 

Dissolve a teaspoonful of this in a wineglassful of ice-water ; and 
give of that two teaspoonfuls every five minutes ; followed each time 
by a lump of ice. 1 Iced water, or rice-water, to which common salt 
and carbonate of soda have been added, may be given, a little at a 
time, as a drink. I would also give a tablespoonful of brandy every 
hour or two. 

Friction of the limbs with brandy and red pepper will be, along with 
large mustard-plasters on the back and pit of the stomach, useful to 
promote reaction. 

The third stage is that of absolute collapse ; blue, pulseless, 
shrunken, voiceless. Should a case go on, in spite of the above-men- 
tioned treatment, into this state, what else can be done ? All now 
seems to be desperate experimentation. 2 Let the ice-bags be tried, 
and judge them by the trial. I would also try belladonna internally, 
as an antagonist of vascular spasm. Leclerc, of Tours, introduced it 
in 1854; Barraut, of Mauritius, used it (| grain every half hour), and 
reported success. He also employed hypodermic injections of sul- 
phate of atropia. This should be tried again in bad cases. So might 
be, as was suggested by me in 1855, ivarm baths of infusion of stra- 
monium (Jamestown weed) leaves; on the same indication. Also, 
the injection of hot liquids into the rectum ; the warm bath (hot baths 
cause distress in the collapse), with carbonate of ammonia added, as 
used sometimes in malignant scarlet fever (West) in children ; or, the 
warm mustard bath. Hot air 3 bathing, if practicable, in the manner 
so praised of late by Erasmus "Wilson and others, would be worth 
trying ; and so would the inhalation of nitrous oxide. Let us con- 
fess honestly, for it is wise to do so, our art is here very weak ; fifty 
per cent, or more of collapsed cases die; shall we not endeavor to 
discover new resources ? All honor to those who, at the risk of 
their own lives, contend yet, with so forlorn a hope, and so little glory 
to be won. There is room yet for, and possibility of obtaining, a final 
triumph. 

1 I take from Dr. Aitken's Practice the following recipe, much used and 
approved in India and England : fy.. — 01. Anisi, 01. Cajuput., 01. Juniperi, aa 
fcss; JEther, 5ss; Liq. Acid. Halleri (*. e. one part concentrated sulphuric acid 
to three parts of rectified spirit), 3SS ; Tinct. Cinnam., gij. — M. Dose, 10 drops 
every £ of an hour, in a tablespoonful of water. 

2 Duchaussoy and Vernois assert the non -absorption of medicines given by 
the stomach during the collapse ; but Magendie proved that a very slow absorp- 
tion does occur. 

3 Dr. George Johnson states that he has seen the hot-air bath used without 
success. 



RHEUMATISM. 315 

Two words remain still to be said, with short comment: house to 
house visitation, and houses of refuge. These are measures of great 
consequence, shown to be of value during cholera epidemics. The 
latter, especially, is of notable importance ; that is, the establishment 
of houses of refuge in salubrious places, into which persons from tainted 
districts most liable to the disease may be received, on the occurrence 
there of the first cases. 

That there are such tainted districts, has been amply proven. Thus, 
Dr. Laycock has shown that in York, England, the first death from 
cholera occurred in the spot where plague had been traditionally the 
worst, in a badly-drained district. In Edinburgh, the first case in 1848 
occurred in the same house as did the first in 1832. In Holland, at 
the town of Groningen, in 1832 and 1848 but two houses in the better 
part of the town were attacked ; the same houses exactly in both epi- 
demics. 

Dr. Alison reports that in the first three months of the epidemic at 
Edinburgh, in 1832, 353 persons were taken in at Houses of Refuge, 
from 70 tainted districts, houses, and rooms in which decided cases or 
deaths had occurred. Of these, only 15 took the disease, and 7 died 
after removal. Of the 346 thus surviving brief exposure, it is very 
probable that more than half would have died had they remained in 
the midst of the infection. At Glasgow, in 1849, 401 persons were 
taken into Houses of Refuge from tainted districts ; only 19 of these 
took the disease and but 5 died. At Oxford, England, the same year, 
of 70 persons so taken in, none died. The London Board of Health, 
in its " General Report," gives the fact that of 1691 of whom the 
Board had accounts as taken into Houses of Refuge, but 33 were 
attacked, with only 10 deaths. These numbers would have been 
larger, but for the very common unwillingness of poor and ignorant 
people to leave their homes, chiefly from want of confidence in the 
greater safety of so doing. Could this be overcome, I have no doubt 
that an immense saving of life might be produced by Houses of Refuge, 
allowing also the places which are proved "foci of infection" to be 
thoroughly purified at once. 

House to house visitation, by sanitary inspectors to abate nuisances, 
small and great, and by medical men to treat premonitory symptoms, 
might also have great preventive value. The establishment of cholera 
hospitals may be made necessary when the number of cases is great, 
especially as the greatest proportion always happens among the poor, 
who are ill provided for attendance at their homes. 

RHEUMATISM. 

Several affections are, in popular language (partly sanctioned by 
medical usage), included under this term. 1. Acute articular rheuma- 
tism, or rheumatic fever. 2. " Chronic rheumatism," affecting the 
joints and sheaths of the muscles. 3. Syphilitic rheumatism, of the 
long and flat bones. 4. " Rheumatoid arthritis." 5. Myalgia. 6. 
u Gonorrheal rheumatism." 

Acute Rheumatism. — Only certain persons and families are liable 
to this affection, upon any exposure. It is characterized by high 
fever, with severe inflammation of several of the larger and smaller 



316 DIATHESES. 

joints; which, mostly one after another, become swollen, red, hot, 
tender, and painful. The shoulders, wrists, knees, and ankles are 
most frequently so affected. Although with a full and rapid pulse, 
the skin, after the first week or so of the attack, is often bathed in 
perspiration. The duration of an attack under various modes of 
treatment has averaged nearly three weeks. Sometimes it extends 
over months ; and the sequelce, or resulting crippling of the articula- 
tions, may remain for a lifetime. 

The danger in rheumatic fever consists in the liability to endocar- 
ditis and pericarditis. A singular complication of it, occasionally met 
with at a late stage, is chorea. Rheumatism may undergo metastasis 
from the joints to the bronchial tubes (rheumatic bronchitis), or, much 
more rarely, to the membranes of the brain. In feeble persons, the 
bowels or the womb may occasionally be involved. 

The blood in acute rheumatism is found to contain an excess of 
fibrin. Lactic acid has, upon some basis of observation and experi- 
ment (Richardson), been asserted to be in excess in the blood as the 
characteristic pathological element in rheumatism. 

Apart from the cardiac affections possible in its course, rheumatic 
fever is not often dangerous to life ; but it is very painful and debili- 
tating. 

Treatment. — Many methods have been and still are in use. Cal- 
omel and opium ; opium alone, or with ipecac, as in Dover's powder; 
lemon-juice ; quinine ; colchicum ; and alkalies ; these are the most 
important. My conclusion upon the subject is, that the alkaline 
treatment is the best by far. Recoveries under it have, in my own 
practice as well as elsewhere, taken place several times within a week, 
where the symptoms indicated a probably long attack. Carbonate or 
bicarbonate of potassa, with the Rochelle salt or nitrate of potassa 
(in scruple doses of the carbonate, or half drachm of the bicarbonate, 
with about the same of either of the other salts), thrice daily, will 
answer [F. 37, 45, 46]. Opiates, especially Dover's powder, at night, 
may do great good. Local application of laudanum (detained by oiled 
silk) to the painful joints, gives great relief. 

Lemon-juice has seemed to me a useful adjuvant (tablespoonful 
doses every three hours) in cardiac inflammations of rheumatic origin. 

Quinine is sometimes very beneficial in enfeebled cases, with free 
perspiration. 10 or 15 grains may be given in a day. 

Colchicum is of decided service only in the presence of the gouty 
diathesis. 

Remarkable success has recently been reported in the treatment of 
rheumatism by " flying blisters ;" i. e., the successive application, to 
different affected parts, of small blisters ; allowed to produce moderate 
vesication only. Several British physicians laud this practice. 

Propylamin I believe to have been fully tried and found wanting 
in value. 

Chronic Rheumatism. — Any one may have this affection, which 
is, however, most common in those advancing in age. It is a sort of 
slow inflammation of the fibrous tissues investing the joints and 
muscles, following exposure to cold and wet. The aching pains are 
apt to be worst at night. 

Cold may produce pain, without any inflammation. Five minutes' 



RHEUMATISM. 317 

exposure to a draught of damp air will often so affect different parts 
of the body ; — relief being at once obtained on the application of 
warmth. This fact, of cold directly producing pain, especially in the 
muscles, ought not to be overlooked. It supports Inman's and Rad- 
cliffe's idea, that pain is always a sign of the local diminution of vitality. 

The treatment of chronic rheumatism has been largely experimental. 
The medicines most given are iodide of potassium, guaiacum [F. 167], 
oil of turpentine, and cod-liver oil. Alkalies and colchicum do not 
signally affect it. Opium is seldom required unless locally. Local 
treatment generally does more for it than medicine. For this, various 
liniments are useful. I have found none better than those containing 
oil of turpentine, oil of sassafras, ammonia, and laudanum, diluted with 
soap liniment ; or, where pain is considerable, chloroform or aconite 
liniment. Blisters may be applied in obstinate cases. 

Dry cupping to the back, leaving a number of cups on for twenty 
or thirty minutes at a time, makes a more pervading favorable im- 
pression, sometimes, than might have been expected. For rigidity of 
the joints, and even for pain in them or in the muscles, 'pouring hot 
water continuously over the parts does great service. The hot bath, 
or vapor bath, or, as some prefer, the hot dry-azr bath (130° to 200°) 
will be powerful for relief in many cases. Galvanism also will aid in 
hastening the restoration of use to the stiffened parts. Wrapping 
rheumatic joints in cotton is often very serviceable. Those subject 
to rheumatism should wear flannel the whole year. 

Syphilitic Rheumatism. — As stated already, this affects the long 
and flat bones chiefly, and mostly between the joints, not at them. 
Generally there is nodosity upon the bones affected, or some degree 
of periosteal inflammation, at least. 

The remedy for syphilitic rheumatism is iodide of potassium. I 
have never known it to fail to relieve the pains in a very few days. 
They may return in the course of months or weeks, when the same 
treatment should be renewed. (Ten to twenty grains of the iodide, 
thrice daily, will suffice) [F. 168]. 

Rheumatoid. Arthritis. — This designation is applied by authors to 
a form of subacute or chronic inflammation of one or more large 
joints, of greater severity than ordinary chronic rheumatism. Effu- 
sion into the joint, with deformity and permanent or at least long con- 
tinued lameness, may occur. I doubt the influence of the gouty 
diathesis in this affection ; while constitutional debility no doubt often 
promotes it. 

Can rheumatism and gout ever actually be combined in the same 
patient, in a hybrid attack ? I am sure that they can, at least, be so 
far blended together, that inflammatory rheumatism, in a patient of 
gouty constitution, is more affected by the state of the digestive 
organs, and is more beneficially acted upon by colchicum, than in 
others. I will consider the diagnostic comparison between rheuma- 
tism and gout hereafter. 

Myalgia. — Dr. Inman, of Liverpool, first gave this name to mus- 
cular pain without inflammation or other defined disease. It is more 
often met with in the back and chest than elsewhere. Debility and 
fatigue are its principal causes ; although, as I have said, muscular 
pain may follow from the direct impression of cold. 

27* 



318 DIATHESES. 



Best, warmth and tonics meet the general indications for the treat- 
ment of myalgia. Anodyne applications, as aconite liniment or tinc- 
ture, or veratria ointment, will be required only in a few cases. The 
hot bath or douche will often give relief. 

Gonorrheal Rheumatism.— After Sir Astley Cooper, several 
English and French writers have described a peculiar inflammation 
of one or more joints, occasionally commencing in the course of 
gonorrhoea, or even of urethral inflammation from forced catheterism. 
The local affection may be severe, with suppuration in a few cases, 
and anchylosis of the joint in many. It appears to be an ichorhcemic 
affection ; i. e., the result of absorption into the blood of morbid 
matter effused into or formed in the membrane of the urethra. 

Treatment. — Chambers and Brodhurst, on the ground of experi- 
ence, recommend active treatment for this affection ; by moderate 
bleeding, general in the robust, and local in others ; followed by blis- 
ters, the hot air bath, muriate of ammonia, and opiates at night. 

GOUT. 

Synonyms. — Podagra ; Arthritis. 

Gout is a diathesis, or constitutional disorder, more or less persis- 
tent, with local affections, mostly inflammatory, occurring, in parox- 
ysmal attacks. 

Symptoms. — Premonition of a gouty spell is often witnessed for 
some days, with symptoms of indigestion ; flatulence, acidity, constipa- 
tion, palpitation of the heart. Then (or without such warning) a joint 
becomes very painful, swollen, red, and tender. In a majority of cases 
the great toe is affected. Other toes, the fingers, ankle, wrist, or knee, 
may be attacked; the large joints least often. Towards the end of the 
spell, tophaceous or chalk-like deposits (chiefly of urate of soda and 
lime, altering with time in part to carbonates) are thrown out about 
the joint, in some but not in all cases. 

The suffering with the gouty inflammation is often very intense ; but 
its duration is not commonly more than a few days at a time. Apt- 
ness to return, at intervals shortening with each attack, is an unplea- 
sant feature. When the period of release is so short as to be almost 
absent, it is called chronic gout. 

Retrocedent or Misplaced gout is that in which, instead of the 
small joints, some internal organ is affected ; as the stomach or heart. 
Such attacks are violent and threatening to life ; but generally brief. 
Exposing an inflamed gouty foot to cold may thus " drive in" the 
disease, or produce a metastasis. 

If the stomach be so involved, nausea, vomiting, and sense of 
spasm or cramp of the stomach are experienced, which, unless relieved 
in a short time, prostrate the patient very much. When the heart is 
the organ seized, its action is interfered with so as to cause distress 
in breathing, pallor, faintness, and debility. 

The urine, during the attack of gout, is scanty, with its usual 
amount of urea, but a deficiency of uric acid, until near the close of 
the spell ; when the latter is increased. The perspiration not unfre- 
qucntly contains an excess of uric acid and the urates, particularly 
urate of soda. 






GOUT. 319 

Hereditary gout is sometimes genuine Podagra, or foot-gout, but 
more often is of the wandering kind. Neuralgia, indigestion, palpita- 
tion, aud urticaria or eczema upon the skin, are its most common 
manifestations. In such a system, rheumatism and other affections 
are to a considerable degree modified by "the gouty tendency. " ; 

Morbid Anatomy. — Except the deposits of urates about the joints. 
and the proved excess of uric acid in the blood, the only peculiar 
alteration belonging to the anatomy of gout is, the shrinking and 
granular degeneration (with some deposit of urate of soda) of the 
kidney; the " gouty, contracted kidney" of Todd. The urate de- 
posit is pathognomonic of gout. 

Pathology. — Garrod has established the doctrine of the character- 
istic of gout being excess of uric acid in the blood. The origin of this 
excess is still doubtful. The view of Mialhe is plausible, that, urea 
being more highly oxidized than uric acid, deficiency of oxygenation 
of the blood may increase the amount of uric acid in it, unchanged. 1 
Also, imperfect action of the kidneys may. by their not depurating 
the blood fully, induce the same accumulation. 

Causation. — High living, with indolent habits, generates gout. 
Even excess of animal food, with scanty exercise, I have known to 
produce it. But strong wines and malt liquors much increase the 
tendency. Weak wines do not seem to have the same effect. In the 
Rhine region gout is rare. Nor do spirits produce it readily ; their 
effects, when abused, are different, though worse in the end. Heredi- 
tary transmission of the gouty constitution is very common. 

Diagnosis. — Between gout and rheumatism there is great resem- 
blance ; and. as I have observed, they may be blended together. 
When clearly exemplified, the following differences exist : — 

In gout, the small joints are chiefly affected ; in rheumatism, the 
larger joints. Repetition of attacks is much more frequent in gout; 
their duration is greater in rheumatism. In gout, the heart is seldom 
attacked, and spasmodically ; in rheumatism, the heart is often subject 
to inflammation. In gout, the stomach is sometimes spasmodically 
affected, with violent symptoms ; in rheumatism, almost never, although 
the bowels may be. In gout, and not in rheumatism, uric acid (or 
urate of soda) is in excess in the blood. In pure gout, colchicum 
generally does good; in pure rheumatism, hardly ever. 

Treatment. — During the attack, colchicum and the alkalies are the 
remedies. Wine of the root (some prefer that of the seeds) of colchi- 
cum may be given in ten to twenty drop doses several times daily. 
The stomach and bowels are sometimes irritated by large doses ; but. 
for a few days, most patients will bear fifteen drops thrice daily. It 
should be stopped when relief has been obtained. Carbonate of 
potassa. ten to thirty grains at once, with half drachm doses of 
Rochelle salt, will be important in addition [F. 37, 45, 46]. Opiates 
or other anodynes may be craved by the patient during the extremity 
of his pain. 

Shall any local application be made ? Not cold to reduce the in- 
flammation. More than one death has occurred from this, by repulsion 
of the disorder to the heart, stomach, or brain. Laudanum may, I 

1 Headland and others advocate a quite different view. 



320 DIATHESES. 

believe, be safely applied to the part, as in rheumatism, by wetting a 
piece of linen or muslin with it, laying it on the painful joint, and 
covering it with oiled silk. Alkaline washes (not too cold) are some- 
times used. 

Gouty attacks affecting the stomach or heart spasmodically are 
usually sudden, violent, and prostrating; requiring prompt stimulation, 
as by brandy, laudanum, Hoffmann's anodyne, chloroform, or Warner's 
cordial (tinct. rhei et sennae). Small or moderate doses of one or 
another of these should be given at short intervals. Mustard plasters 
to the epigastrium, or chest, and back, will be important; and the feet 
may be placed in hot mustard water for revulsion. 

Breathing oxygen has been lately proposed as a remedy for the 
gouty state of the blood. Its utility has not yet been decided upon 
by sufficient trial. - 

The prevention of attacks, by the removal of the diathesis and pre- 
disposition, is often very difficult, even in the absence of hereditary 
taint. Regulation of the diet is of primary importance. But it 
should not be too low, especially when the patient's habits have been 
those of a free liver. Nourishment must be full, while the digestive 
power is economized, and positive stimulation avoided. Exercise, in 
proportion to strength, should be recommended. In some weak or 
old cases, tonics may be called for; vegetable bitters particularly. 
The state of the skin and that of the bowels are important. 

Change of air, travelling, and mineral waters, are generally useful 
during the intervals between the paroxysms. Alkaline springs and 
baths (such as that of Vichy in France, or Ems in Germany) have an 
especial reputation as prophylactic against gout. 

SCURVY. 

Synonym. — Scorbutus. This affection was once very destructive 
to voyagers at sea, and explorers of barren regions, as well as, some- 
times, to large armies. Captain Cook has the credit of proving the 
preventive value of vegetable food. Dr. Lind, his cotemporary, pub- 
lished a work on scurvy in 1757, advocating the anti-scorbutic use of 
oranges and lemons. Still, in their Arctic expeditions, Drs. Kane 
and Hayes were much incommoded by this disease. In the Crimean 
war, and during the late rebellion in this country, although uncompli- 
cated scurvy was not very frequent, the scorbutic diathesis modified 
other diseases and increased mortality to a serious extent. 

Symptoms. — Languor, debility, and lowness of spirits first occur. 
Then swelling, sponginess, and bleeding of the gums are observed ; the 
teeth loosen, and the breath is offensive. Palpitation of the heart 
and dyspnoea may be present. Petechial spots (from subcutaneous 
extravasation of blood) appear on the limbs ; sometimes the legs swell 
from fibrinous deposits, especially at the ham. Diarrhoea and dysentery 
often come on. Death may take place by gradual exhaustion, or by 
sudden syncope. 

Diagnosis. — Purpura hemorrhagica is undoubtedly not identical 
with scurvy, although " purpuric" extravasations are common to both. 
Purpura does not depend, as scurvy does chiefly, upon a fault of diet ; 
nor are the gums affected in purpura. 



SCORBUTIC DYSENTERY. 321 

Causation and Pathology. — That the essential cause (sine qua 
non) of scurvy is deprivation of fresh food, and, in almost all cases, 
of fresh vegetable food, is proved. Fresh meat will retard it, in the 
absence of vegetables ; but neither this nor oranges and lemons will 
altogether prevent it, through long periods. Additional promotive 
causes are severe cold, fatigue and exposure, and mental anxiety or 
home-sickness. 

Further than this, the pathology of scurvy has not been determined. 
The hypothesis that it depends upon deficient alkalinity of the blood 
is disproved by the failure, in many hands, of potassa and its com- 
pounds to hasten the cure, or insure prevention. 

Treatment. — Medicine here is almost valueless. Fresh vegetables 
alone will restore what is wanting, though chemistry has not detected 
the nature of the need. Potatoes, tomatoes, oranges, lemonade are 
the three most generally available articles. If any medicine is useful 
as an adjuvant, it is the tincture of the chloride of iron, in moderate 
doses. Sometimes citric acid does good. 

For the gums, a wash of solution of tannic acid or tincture of myrrh 
in diluted glycerin will be useful ; or alum, brandy and water. Salt 
and whisky rubbing to the skin will aid in dissipating the petechia?. 

Prophylaxis, — Medical men in charge of expeditions to a distance 
from ordinary supplies should always insist on measures being taken 
to furnish enough fresh vegetables, or, next best, desiccated potatoes. 
After the latter, onions, tomatoes, turnips, &c, and oranges and lemons 
rank. Wine is also decidedly though not infallibly scorbutic. The 
leaves of the pokeberry plant (phytolacca) and of the cactus opuntia, 
are so. Raw meat is better, in the arctic regions, for the same end, 
than that which is cooked. The experience of the Army of the Poto- 
mac, during the late war, in the M'Clellan campaign, shows that neglect 
of the means of preventing this disease will sometimes cost far more 
than those means themselves, whatever difficulties they may seem to 
present. t 

SCORBUTIC DYSENTERY. 

This term appears prominently in the sanitary and medical reports 
of the armies in the Crimea. In the peninsular campaign in our late 
war (just alluded to above), the Chickahominy region was the seat of 
a great amount of disease, partly febrile (typho-malarial fever) and 
partly scorbutic. While on duty in the summer of 1862 in two U. S. 
Geueral Hospitals in this city, I met with many such cases. A record 
was especially kept of thirteen deaths in the Fourth Street Hospital, 
from what I then designated as "scorbutic marasmus." 

These men were brought from the Chickahominy very much ema- 
ciated, pale, feeble, without appetite, almost without power of 
digestion, and with moderate diarrhoea. Vomiting occurred in some. 
Blue or nearly black purpura or petechial blotches appeared on their 
arms and legs; in the fatal cases, over the breast and abdomen also. 
But one of our men recovered in whom the extravasations occurred 
on the breast ; a considerable number in whom only the limbs were so 
affected. 

The diarrhoea was in none of them so great as of itself to threaten 



322 DIATHESES. 

life. Several improved under treatment for a while, and then relapsed 
into a condition not unlike in aspect to the collapse of cholera ; in 
which they died. Two, after seemingly great improvement for a week 
or more, died suddenly. It seemed that, in them, the blood or blood- 
making power was hopelessly ruined. 

Autopsy, in several of these, and in some patients in another ward 
of the same hospital, under the care of Prof. S. D. Gross, exhibited 
coincident lesions not often described together. These were, the 
signs of extensive follicular colitis, and those of double pneumonia. 
The latter invariably affected the posterior portions, only, of the 
lungs. Suppuration had occurred in the lungs in two of our cases ; 
hepatization in three or four more. 

The condition of the bowels in those instances was thus recorded 
in my notes. 

The large intestine, especially the rectum, was extensively inflamed ; 
with large, rugose tumefaction, the ridges covered thickly by an ash- 
colored granular and diphtheritic deposit ; the whole surface reddened 
underneath this, and the bloodvessels generally enlarged. No pus 
was found ; and only slight, rare, and superficial spots of ulceration. 
The ileum also was affected with marked hyperemia and swelling of 
the mucous membrane, without ulceration. 

I give these facts and appearances as matters of medical and patho- 
logical history. The occasion of their occurrence, we may well trust, 
will never occur again in this country. 

SYPHILIS. 

Few old subjects have been so completely re-opened lately as that 
of syphilis. Twenty years ago, not many denied the unity of the 
syphilitic poison (distinct from that of gonorrhoea), while all admitted 
the multiplicity of its manifestations. Soft chancre, indurated chancre, 
and phagedenic chancre were all recognized, as well as the specific 
bubo, and secondary and tertiary syphilis. But now, prominent 
authorities urge that at least two poisons exist, productive of vene- 
real diseases, not mutually inoculable or convertible. This I am not 
satisfied to pronounce proven. The topic is altogether rather surgi- 
cal than medical ; but, as the physician must often deal with it, I pro- 
pose to state (perhaps, for brevity's sake, rather dogmatically) what 
I conceive to be the most important practical points. 

The " Hunterian" chancre is a sore on the male or female genitals, 
slightly cup-shaped, upon an indurated base. From ten days to a 
month or more elapse usually after infection before the chancre is 
perceived. Then it begins as a red pimple, often unnoticed until it 
ulcerates. Its secretion is moderate in amount, and scarcely purulent 
except under irritation from without. 

This is said not to be " auto-inoculable ;" i. e., matter from it will 
not, if introduced anywhere on the patient's own body, produce a like 
sore. The lymphatic glands may become affected, with enlargement 
and hardening, not suppurating unless disturbed and inflamed. The 
constitutional disease, called in its manifestations secondary and ter- 
tiary syphilis, results from infection by this sort of chancre. 

The •• simple, soft" chancre is described as having no period of incu- 



CONSTITUTIONAL SYPHILIS. 323 

bation, and not commencing as a pimple or tubercle, but as an abra- 
sion, which discharges pus. If a bubo follow it. it is the suppurating 
kind. The system is said, by recent authorities, not to be involved 
by this. 

"Phagedenic chancre is characterized by unhealthy purulent dis- 
charge and a destructive tendency to erosion. Ulceration of the 
groin may follow its buboes. Sloughing chancre may be regarded as 
the extremest degree of this, observed under conditions of depressed 
vitality. 

Xow in the above discrimination between u infecting" and "non- 
infecting" chancre, the former being considered to be only that with 
indurated base and non-suppurating buboes. I follow late authors, not 
my own observation. A moderate, but not inconsiderable experience 
in the treatment of syphilis, in hospital and private practice, impresses 
me with different opinions ; viz., that either the hard-based or the sim- 
ple soft chancre may have a suppurating bubo and a decided consti- 
tutional affection. I must assert that I have seen those results, re- 
peatedly, follow both. 

Treatment. — Without claiming opportunity to have put to the test 
all the different ideas, my conviction remains strong, that for all forms 
of primary syphilis except the sloughing or the extreme phagedenic 
variety, mercury is the specific antidote. I have not seen reason to 
believe in the efficacy, in primary syphilis, of any other medicine, in- 
ternally administered. 

Blue mass, calomel, iodide of mercury, etc.. all have the effect. Enough 
must be given to produce the impression of mercury upon the system ; 
but decided salivation is not necessary. I never positively salivated 
more than two men ; one who had a bad chancre under a phymosis, 
and another peculiarly susceptible to ordinary doses. A grain of blue 
pill thrice daily, or half a grain of calomel as often, or from half to a 
grain of iodide of mercury [F. 169] twice a day. will do. The earlier 
it is begun with, the better. 

Local treatment is also important. The caustic use of nitrate of 
silver (some prefer the stronger potassa caustic), used early, may kill 
the specific disease at the spot. To do so. it must burn out the whole 
substance of the chancre. After such application, astringent lotions, 
as lime-water, solution of sulphate of copper (gr. £ to gr. j in fgj), 
&c, may be applied, washing the part gently twice a day with castile 
soap and water. Many cases thus treated, early, will get well without 
taking any mercury. In obstinate venereal sores, however, sprinkling 
the part with powder of calomel is one of the most effectual remedies. 
The calomel air or vapor bath has lately been recommended. 

Buboes, if they inflame, may be leeched and refrigerated with lead- 
water or soothed with poultices. TThen they suppurate, let them be 
freely opened with a bistoury. When, afterwards, they refuse to heal, 
the surgical treatment proper for indolent ulcers will be suitable for 
them ; besides the local use of powder of calomel. 

CONSTITUTIONAL SYPHILIS. 

Weeks or months after the primary disease, secondary syphilis may 
show itself. Once produced, although sometimes readily curable, it 



324 DIATHESES. 

often impairs the constitution for life, and transmits the taint to off- 
spring. 

The affections belonging to secondary syphilis are — peculiar copper- 
colored eruptions, rupia especially ; warts about the genitals ; ulcers 
of the throat ; iritis ; loss of hair (alopecia) ; affections of the testicle 
or uterus. These last, as well as periostitis and osseous tumors or 
nodes, cutaneous tubercles, and chronic degenerative inflammations of 
the brain, spinal marrow, liver, spleen, lungs, &c, are often called 
tertiary syphilis. 

General experience and opinion have asserted that constitutional 
syphilis is not transmissible by inoculation. Some recent experiments 
have placed this question again " sub judice." 

Treatment. — Mercury is available in the treatment of secondary 
as well as primary syphilis ; but its power over it is less^absolute. 
After moderate trial of its impression (especially of the iodide of mer- 
cury) , iodide of potassium may be given ; from ten to thirty grains 
thrice daily. It is an almost certain cure (I have never known it to 
fail) for syphilitic "rheumatism" or bone pains, with or without nodes. 
Over ulcers of the throat, also, it has great power. Such things, how- 
ever, often do not stay cured ; they break out again, as may also the 
cutaneous eruptions ; requiring the same treatment over and over. 

Donovan's Solution,* internally, and mercurial ointment locally, are 
the only additional remedies among many proposed and often used, 
that I think i,t worth while to name in our brief consideration of the 
subject. Of course, enfeeblement of the constitution of the patient 
may require the employment of generous diet, salt bathing, change of 
air, iron, quinine, or cod-liver oil. 

SYPHILIZATION. 

Among the most remarkable curiosities of medical history is the 
attempt lately made to prevent, and even to cure syphilis by inocula- 
tion with the syphilitic virus. Auzias Turenne, Sperino of Turin, and 
Broeck of Ohristiania, have especially urged their assertions of suc- 
cess with this process. The immunity is said, like that of vaccination, 
to last for life. Out of place as it would be to discuss it here, it must 
be said only, that, after reading a good many pages of the evidence, 
pro and con, I do not find that, as yet, positive proof enough has been 
afforded to overcome the strong a priori improbability of it. Also, 
those who advocate it admit that it is a slow method of cure, as well 
as far from agreeable ; and as to its prophylactic use, few physicians, 
at all events in this country, are likely to recommend it to their pa- 
tients instead of avoidance of the cause of the contamination. 

GONORRHCEA. 

Very few words must suffice us upon this topic. Gonorrhoea is a 
specific urethritis ; in the female, also, vaginitis ; produced by impure 
sexual congress. Its symptoms are, pain and soreness, redness and 
swelling, of the penis, with early and continued suppurative discharge. 

1 Liquor Hydrargyri et Arsenici Iodidi. Dose, 3 to 5 drops. 



GONQRRHCEA. 325 

Burning pain on passing water, and chordee, or painful rigidity of 
erection, are the principal causes of suffering, while the patient is at 
rest. "Walking about aggravates very much the soreness and pain. 

Urethritis, or balanitis (inflammation of the glans penis), may occa- 
sionally be brought on by contact with the matter of leucorrhcea, or 
the menstrual discharge. No perceptible difference exists in the 
symptoms, in this case, from gonorrhoea ; but the latter is more obsti- 
nate, and is itself directly contagious. Such non-specific urethritis 
is, moreover, a very rare disorder. 

The period of incubation of gonorrhoea is sometimes but a day ; 
seldom many days. Its duration is ordinarily from ten days to three 
weeks. But a gleet, or chronic discharge, more or less muco-purulent, 
without active inflammation, may be left behind, of indefinite con- 
tinuance. 

Sympathetic non-suppurating bubo may attend gonorrhoea ; so may 
also orchitis, or inflammation of the testicle. Gonorrhoeal rheuma- 
tism is sometimes met with, ascribed to a metastasis or repulsion of 
the local affection to some of the joints. 

Treatment. — At first, during the height of the inflammation, rest 
in bed, low diet, Epsom salts, and free draughts of flaxseed tea, com- 
prise the best treatment. It is true, there is a period at the end of 
incubation, when the symptoms are just commencing, when abortive 
treatment maybe practised; as by a strong injection of nitrate of 
silver (gr. vj to gr. x in fgj) into the urethra. This is a bold and 
rather uncertain measure, however. 

Bathing the penis frequently in warm water is very soothing to the 
pain and soreness. Chordee may be treated by that means, and by 
suppositories of opium and cocoa butter. A pill of camphor and 
belladonna (camphor five grains, ext. belladonna half a grain) at bed- 
time, will be useful in preventing chordee. 

As soon as the activity of the urethritis has subsided, injections 
may be used: of nitrate of silver (gr. j to gr. iv in f,§j), acetate or 
subacetate of lead (subacetate, gr. xv in f5j), sulphate of copper (gr. j 
in fgj), sulphate of zinc (gr. ij in fgj), or chloride of zinc (gr. j in 
f§j). Glycerin may be added to the water for either of these solutions, 
with advantage. 

Copaiba and cubebs are, time out of mind, medicines for gonorrhoea. 
Without any specific antidotal properties, they come in well, one after 
the other; first the copaiba, and then the cubebs (in half fluidrachm 
doses of the former, in mucilage, and ten to twenty grain doses of the 
latter), when the inflammation is subsiding [F. 174, 175]. 

For gleet, which is often very annoying, local treatment, with regu- 
lation of the diet (avoiding stimulants and condiments), must be 
depended on. Injections, of the same character as those above 
alluded to, may be repeated. Should they fail, a bougie smeared with 
an astringent ointment should be introduced every day or two, and 
left in the urethra for ten or twenty minutes. Ointment of nitrate of 
mercury; of carbonate of lead; spermaceti ointment; and ointment 
of nitrate of silver, are all recommended. A. flexible bougie, of cacao 
(cocoa) butter will irritate the least. Yery obstinate cases have 
sometimes been cured by the introduction of solid nitrate of silver by 
the porte-caustique. 
28 



326 DIATHESES. 

Examination with the endoscope (recently introduced for specular 
examination of the urethra) may detect the exact spot which is the 
seat of the irritation and discharge. Blistering the perineum is 
practised by some, for gleet. Constitutional treatment, by tonics, 
may be called for when general relaxation maintains the complaint. 

SCROFULA. 

Prof. Aitken' defines (scrofulosis or) tuberculosis as follows : — 

41 A particular morbid condition of the system, attended by a per- 
sistent increase of temperature, followed by a continuous wasting of 
the body and the growth of a substance in various tissues and organs, 
especially the lungs, to which the name of tubercle or tuberculous 
matter has been applied. These phenomena are associated with pecu- 
liarities of outward appearance during life, and liability to certain 
diseases termed scrofulous, such as swellings of lymphatic glands and 
of joints, carious ulcerations of bones, frequent and chronic ulcera- 
tions of the cornea, ophthalmia, abscesses and cutaneous pustular 
eruptions, persistent swelling and catarrh of the mucous membrane 
of the nose, and characteristic thickening and swelling of the upper 
lip — lesions which, while they are distinguished by mildness of symp- 
toms, are peculiarly persistent, and follow the application of exciting 
causes which would have no effect on a healthy person." 

Scrofula is the term applied commonly to those of the above 
named local affections involving (most frequently in rather early life) 
the glands, bones, nose, ears, and eyes. The tubercular diathesis 
has already been sufficiently considered for our purpose and space. 
(See General Pathology.) A very few words of a practical bearing 
must be added. 

The causes of scrofula are, chiefly, "hereditary transmission, and 
deprivation of pure air. The former is well known to all. Baude- 
locque, McCormack, and Greenhow, among others, have proved the 
latter most thoroughly. All depression of the system by low living, 
such as insufficiency of food and warmth, &c, will promote it. It has 
been imagined, not proved, that the syphilitic taint of constitution 
may glide into it. 

In treatment of scrofula, in any of its forms, but particularly in 
chronic enlargements, with or without cheesy softening, of the lym- 
phatic glands (of the neck, armpit, or groin), iodine has general 
confidence [F. 176]. It is not, however, infallible. Iodide of ammo- 
nium (dose 3 grains) is now coming under trial. The external appli- 
cation of iodine to tumors, scrofulous or other, " to produce absorption," 
will very frequently disappoint. 1 am not sure that it has, locally, any 
effect but as a stimulant or irritant. That may sometimes be useful. 

Cod-liver oil is also an anti-strumous remedy of great power; and one 
more readily taken by the young than by adults, generally. Iron may 
be serviceable in many debilitated scrofulous cases. Sea bathing and 
sea air are mostly the best of remedies. Good diet is indispensable. 

The local treatment of so-called scrofulous affections is to a great 
extent surgical. Slowly softening glands may sometimes be cut out. 

1 Science and Practice of Medicine, vol. ii. p. 188. 



CARIES OF THE SPINE. 327 

Scrofulous periostitis, threatening caries, I have seen arrested by free 
application of cerate of carbonate of lead over the affected bone. 
The leg is most frequently the seat of such disease ; but it may attack 
any of the long bones. Removal of diseased or necrosed portions is 
to be recommended rarely, unless they are loosened. Extensive re- 
sections should be very exceptional. 

KICEETS. 

Synonym. — Rachitis. Infants upon learning to walk show the 
cachexia to which this name is given, by yielding of the bones, with 
muscular debility, and general failure of nutrition. The bones are 
brittle from imperfect development ; the spine is apt to become 
curved, and the limbs crooked. The teeth are backward in coming-, 
and fall out with early decay. Tenderness of the surface of the body, 
and irritability of the nervous system, also exist. 

Treatment. — Hygienic measures are of the first consequence. Well 
aired rooms, warm salt bathing, milk or beef-tea diet, cod-liver oil, 
iron, and phosphate or hypophosphite oflime, ail have their value. 

CARIES OP THE SPINE. 

Synonym. — Pott's Disease. 

In scrofulous children of either sex, between two and fifteen years 
of age, sometimes without, but oftener after a fall, blow, or other 
mechanical injury, caries of the body of one, or occasionally two or 
three of the vertebrae may occur. The dorsal region is most fre- 
quently attacked. 

Symptoms. — Pallor, debility, pain in the abdomen, 1 in sudden and 
severe paroxysms ; irritability of temper, stooping forward in walking, 
rigidity of muscles, a cautious, gliding gait, to avoid concussion of the 
spine; loss of appetite, swelling of the belly, uneasy sleep, hurried or 
impeded respiration; tenderness of the spine on pressure, an angular 
deformity or backward projection of a portion of the spine ; paralysis 
in various degrees, abscesses of the back, discharging externally, or 
by the lungs, bowels, vagina ; or, the pus entering the hip-joint. 

Treatment. — Dr. Henry G-. Davis, 2 of New York, claims, and I 
believe with reason, to have introduced an important improvement 
into the treatment of caries of the spine. Of the older methods, the 
best idea was rest to the back, with careful efforts at extension ; and, 
especially in this country by the late Dr. John K. Mitchell, support 
(by means of corsets) dependent upon attachments quite outside of the 
body. Dr. Davis, reasoning upon the fact that the bodies of the ver- 
tebrae are the seats of the destructive process, aims at separating 
these, throwing all the weight upon the oblique processes. The spine 
is relieved then by straightening rather than extending it. 

An apparatus of Dr. C. F. Taylor carries out this and other rational 

1 Dr. B. Lee (Angular Curvature of the Spine, 1867) speaks of "gastralgia" 
as an initial symptom. 

2 Conservative Surgery, 1867. Dr. Davis' first publication on the subject 
was in the Boston Medical and Surgical Journal, August, 1852. 



328 DIATHESES. 

principles of treatment very well. It is thus described :' " A broad 
band passes around the trunk low down, so low that in front it almost 
touches the thighs in sitting. It passes just above the pubes and en- 
tirely below the abdomen, so that the abdomen is sustained upward, 
instead of being, as in most instruments, pressed downward. There 
are two pieces or levers passing up the back, not over the spine, but 
each side of it, so that it is firmly held from lateral deviations. At the 
top is a cross-piece in the form of two T's with the small ends united. 
The object of this arrangement is that the straps may pass directly 
forward and around the arms, and thus prevent a great loss of force 
by diagonal action ; and also that they shall touch the person only 
where the pressure is needed, namely, on the forward part of the 
shoulders. At a part of the instrument opposite the seat of the dis- 
ease, the point where we make our fulcrum, the pads are placed. 
These are made of chamois skin or Canton flannel, and are filled, not 
with cotton, which soon packs and becomes hard, but with long, elastic 
African or East Indian wool, which has no felting qualities. These 
pads are removable when they become compacted. The shoulder- 
straps and bands around the hips are likewise provided with remov- 
able pads to protect the skin against pressure and abrasion. • 

It will be seen that the instrument, like the spine itself, acts like a 
double lever with a common fulcrum at the curvature ; this action is 
directly backward at the hips and shoulders, and directly forward at 
the middle of the back, or wherever the diseased part is located. 

The instrument is provided with several hinges, stop hinges 

in front, but free to bend backivards, which allows the most unre- 
strained use of the muscles of the back useful in causing 

the development of the spinal muscles instead of binding them up and 
causing* their atrophy, as results from the use of instruments which 
prevent muscular action." 

Constitutional treatment, by fresh air and sunshine, nourishing diet 
and cod-liver oil, iron, or other tonics, as well as purgatives (if required, 
as they are in most cases) must be added, of course, to mechanical 
means. Cures are thus sometimes effected in cases once thought 
hopeless. 

Lateral curvature of the spine is very different — depending upon 
muscular weakness or inequality of development. Bad habitual posi- 
tions often cause it. Training the subject of it to use Ms muscles 
properly, and thus develop and strengthen them, must be the leading 
idea in its treatment, apparatus here being quite secondary, though 
perhaps sometimes temporarily needful. 

COXALGIA. 

Synonyms. — Morbus Coxarius ; Hip-Disease. 

Though regarded, like spinal caries, as rather a " surgical" subject, 
a few words may not be out of place upon this theme also. Its etiology 
appears to be like that of disease of the spine ; a constitutional tend- 
ency, tubercular or scrofulous, acted upon in many, though far from 
all cases, by a local injury. Inflammation of the hip-joint occurs, in 

1 Angular Curvature of the Spine, by Dr. B. Lee, p. 70. 



ANEMIA. 329 

some instances acute and violent, oftener active only at first and to a 
moderate degree : not rarely insidious in approach. 

Symptoms of the most characteristic kind are, pain in the knee, 
without any other sign of disease about that part; and a limping gait, 
the knee being bent, the child treading only on the toe of the affected 
limb. Examining the hip-joint, it is found that pressing the head of 
the thigh-bone into it gives pain. Atrophy of the muscles over the 
hip may follow. General weakness and emaciation, with other symp- 
toms of the scrofulous cachexia, usually attend. Suppuration in the 
joint, with chronic abscesses, ulceration of the cartilages, subluxation 
of th#femur, and caries of the bones, with hectic fever and progres- 
sive debility, occur in severe cases. 

Treatment. — Physick's celebrated treatment was, absolute rest of 
the joint by means of a carved splint, passive exercise in the open air 
in a carriage or, if a young child, in arms, — and systematic purgation 
with jalap and cream of tartar. To this, with less stress upon the 
not at all indispensable purging, Dr. Davis has added the use of con- 
tinued elastic extension of the limb, so as to relieve the joint of the 
pressure of the head of the bone in its socket, caused by the contrac- 
tion^ the muscles. This continued elastic extension may be obtained 
in bed, by adhesive plaster strips, to which is suspended, by a cord 
and pulley, a weight, proportioned to the amount of power the muscles 
display, and tested by the comfort secured by it to the patient. Out 
of bed, a splint may be applied, maintaining elastic extension by a 
perineal band, best made of adhesive plaster spread (as proposed by 
Dr. Davis) upon twilled material, and kept for awhile before use so as 
to lose its unctuous property and remain more securely in place. 

Simple inflammation of the hip-joint may, of course, follow an injury; 
and may find relief in a comparatively brief time, from rest, and local 
antiphlogistic measures, as cups, a blister, etc. 

ANJEMIA. 

Something has been said of this subject under General Pathology. 

The causes of anaemia are, most often, either 1. Loss of blood, from 
disease or injury causing hemorrhage. 2. Excessive suckling in a 
mother or wet-nurse. 3. Severe or protracted diarrhoea, or (more 
rarely) leucorrhcea. 4. Typhoid or other form of fever. 5. The 
malarial influence, sustained for a considerable time. 6. Deficiency 
of food, light, warmth, or fresh air. 

Anaemic symptoms are, pallor, slenderness of figure, debility, ner- 
vous excitability, cardiac palpitation. Anaemic murmurs in the heart 
and aorta have been mentioned under Semeiology. 

In the treatment of anaemia, good diet, pure air, and iron or cod- 
liver oil are the essentials. Of the preparations of iron, numerous as 
they are, I have found the most satisfactory results from the tincture 
of the chloride, the pill of the carbonate (Yalleix's mass), the iodide 
(syrupus ferri iodidi), the phosphate, and, in children, the citrate [P. 
202, 203, 204, 205]. Dr. Aitken speaks very highly of the value of a 
combination designated as the " syrup of the phosphates of iron, 
quinine, and strychnia." This formula will be given at the end of the 
book [see F. 2131. 

28* 



330 DIATHESES. 



CHLOROSIS. 

This not very common affection of girls, about the age of puberty, 
is by some regarded as simple anaemia; by others, as a pathologically 
distinct affection. Symptomatically, it is characterized by a peculiar 
waxy, yellowish, or greenish pallor of the face. The lips are also 
nearly colorless, and (as in common anaemia) the tongue often pale. 
Q^dema of the feet or of the face may occur; or a dark circle may 
appear around each eye. Weakness, nervousness, and palpitations 
exist, with somewhat lowered temperature of the body. Einging in 
the ears, lowness of spirits, and disturbed sleep are common. Diges- 
tion is impaired ; and a morbid appetite is sometimes present, as for 
coal-ashes, slate-pencils, chalk, earth, or, in other cases, strong acids. 
Neuralgia, affecting especially the abdominal parietes, or myalgia, 
may occur. Menstruation is either absent (amenorrhcea), irregular, 
or painful (dysmenorrhcea). 

The blood in chlorosis has been found deficient in corpuscles, and 
containing an excess of fibrin. One of the curiosities of medical history 
is the fact that crude theory led at one time to the employment of 
venesection in its treatment, to diminish the amount of fibrin, whose 
excess was supposed to constitute it an inflammatory disease ! 

The duration of chlorosis is variable. It may be protracted for 
years. It is perhaps never, alone, directly fatal. 

In treatment, measures adapted to anaemia are suitable. Good 
diet, sea bathing, change of air, light gymnastics, iron, bitter tonics 
(sometimes even strychnia or nux vomica in small doses) will all have 
their place. Certain cases do not bear iron well, from tendency to 
fulness of the head. Some, even, chlorotic but not anaemic (though 
not on the fibrin theory), need to be relieved of that symptom by the 
application of a few leeches or cut cups to the back of the neck. 

Special attention to the menstrual function will be demanded. Of 
this, a few words will be said in another place. (See Amenorrhcea.) 

BERI-BERL 

This endemic disease of Oeylon and a part of Hindostan, being 
nowhere else met with, needs here to be only defined. This will be 
done in the words of Dr. Aitken : — 

" A constitutional disease, expressed in the first instance by anaemia, 
culminating in acute oedema, and marked by stiffness of the limbs, 
numbness, and sometimes paralysis of the lower extremities ; op- 
pressed breathing ; a swollen and bloated countenance. The urine is 
secreted in diminished quantity. The oedema is general, not only 
throughout the connective tissue of the muscles, but the connective 
tissue of solid and visceral organs in every cavity of the body is bathed 
in fluid. Effusion of serum into the serous cavities very generally pre- 
cedes death." 1 

This disease may occur either in the acute or chronic form. Death 
may follow in a few hours, or be delayed for several weeks. 

1 Science and Practice of Medicine, vol. ii. p. 83. 



LEUCOCYTII^MIA. 331 

Intemperance promotes it. But there must be some undiscovered 
element of local causation. 

Tonics, stimulants, and generous diet would seem to be indicated in 
the treatment of beri-beri. Some native medicines have a reputation 
in India; but the management of the disease does not appear to have 
been satisfactory. Death is seldom averted, either from the first 
attack or after relapses. 

LETJCOCYTH.EMIA. 

We have defined this affection already. (See General Pathology.) 

The history of its discovery, which has been subject to controversy, 
appears to be, in brief, as follows. Dr. Craigie of Scotland reported 
(Edinb. Med. §* Surg. Journal, vol. lxiv. 1845) a case of disease of the 
spleen, examined also by Dr. John Reid, in which a peculiar appear- 
ance of the blood occurred, supposed by them to be "purulent." Dr. 
Bennett of Edinburgh, in 1845, published an account of a similar case, 
describing it as " suppuration of the blood." A month latter, Tirchow 
of Berlin described a case, presenting the same appearances under the 
microscope, as leukaemia, or white blood, asserting the view that 
excess of the colorless corpuscles, not suppuration, was the true nature 
of the affection. While, then, the first facts were Dr. Craigie's, the 
credit of discerning the pathology which explains them belongs to 
Prof. Yirchow. 1 The first diagnosis of the disease during life was 
made by Dr. Fuller of London, in 1845. 

The causes of leucocythsemia are, exposure to cold and wet. pros- 
trating diseases such as typhus, typhoid, or puerperal fever, and affec- 
tions of the lymphatic glands or of the spleen, often of undetermined 
origin. 

Its symptoms are, debility, swelling of the abdomen, anasarca, often 
vomiting or diarrhoea, jaundice, and hemorrhages from the nose or 
gums. The spleen, and, sometimes, the liver, are enlarged. The 
lymphatic glands are often so, also. Cough may occur ; and so may 
pustular eruptions. The tendency of the disease is towards death, and 
it is doubtful whether any case, well marked, has been cured. But it 
is slow, and may extend over many years. 

Diagnosis of leucocythsemia is only possible by microscopic exami- 
nation of the blood. A drop from a needle prick of a finger will suf- 
fice ; placed under a microscope of 250 diameters or more. Instead 
of being but one to fifty of the red corpuscles, the white blood-cells 
may be one to six or four ; perhaps even one to two or three. When 
a larger quantity of blood is drawn, it has, after heating, a whitish or 
milky look. Its coagulum is grayish-white on its surface, from excess 
of the colorless corpuscles. After death, coagula are found in the 
heart, consisting of such corpuscles almost alone. 

We have said that the cure of leucocythsemia has not yet followed 
any of the many remedies tried for it. No doubt life may be prolonged 
under it, by hygienic management, and tonics. Nitric and nitro ; 

1 Prof. Bennett's labored defence of his own claim to priority does not, I 
think, at all contravene the above view. See his "Clinical Lectures, &c. r ' 
2d ed. (X. Y.), p. 892. i 



332 DIATHESES. 

muriatic acids are recommended ; the latter by the bath as well as 
internally. 

PYEMIA. 

11 Absorption of pus" as such, through the walls of bloodvessels, being 
shown to be impossible on account of its cellular nature, the pus 
cells, moreover, beiDg too large to pass through the capillaries, other 
views are now advanced. Under the name pyaemia, indeed, several 
affections are included. 1. Septicaemia or tchorhcemia; i. e., blood- 
contamination from absorption, in a liquid state, of putrescent or 
otherwise morbific material ; 2. Transfer by veins of actual pus, in 
cases of phlebitis, and its deposit in new localities ; 3. Thrombosis, or 
coagulation in a vein during life, followed by embolism, or the con- 
veyance of a portion or portions of coagulum to different parts, 
causing irritation, or obstruction. 

That inflammation of a vein (phlebitis) does not very unfrequently 
occur, there is no doubt. But the external coat and surrounding con- 
nective tissue are generally most involved ; and suppuration of its 
internal lining is rare. Coagulation is much more frequent. Embol- 
ism, however, as well as thrombosis, may, and often does, take place, 
without any of those general symptoms to which the name of "puru- 
lent infection" is given. Most properly, I consider, the name pyaemia 
should be restricted to cases in which, to cite the words of J. Simon, 
" some diseased part (which need not be an external wound) so affects 
the blood circulating through it, that this blood afterwards excites 
destructive suppuration in parts to which the circulation carries it — 
namely, commonly first in the lungs, or (in certain cases) liver and 
lungs, and later, generally about the body." Putrid infection, septi- 
caemia or ichorhaemia, may occur without local suppurations, but 
with symptoms otherwise similar. Clinical convenience may readily 
excuse the designation, common with many, of such cases, by the same 
term, pyaemia. 

Symptoms of such an affection are, chills, low fever, rapidity and 
feebleness of the pulse, prostration, delirium, and swelling of the 
joints. Death may occur in a few days, from devitalization of the 
blood ; or, if purulent formations occur, by exhaustion caused by 
their presence and discharge. 

In the treatment of pyaemia or septicaemia, support and depuration 
of the blood are the indications. Pure air is not only preventive, but, 
positively curative of such affections. Of medicines, the attention of 
the profession is just now especially called to the sulphites and hj-po- 
sulphites, of soda, lime and magnesia, proposed by Prof. Polli, of 
Milan, as antiseptic remedies. They are under trial. Several favora- 
ble cases of their use are reported ; although, in the U. S army, during 
the late war, disappointment was experienced by a number of those 
who employed them. Sulphite of soda may be given safely to the 
extent of four or five drachms daily ; the bisulphite (Wood), about 
half as much, or less. It is certainly proper to give these remedies a 
fair and prolonged trial. 






EMBOLISM — ANGEIOLEUCITIS. 333 



EMBOLISM. 

Cruveilhier, many years ago, proved that in inflamed veins a clot is 
formed, principally fibrinous. Gulliver ascertained that a granular 
degeneration of the central layers of such a coagulum may occur, 
giving a " puriform" character to their substance. Yirchow then 
demonstrated that portions of such clots may be carried from their 
first seat in the circulation, and form plugs in the pulmonary or some 
other artery. Afterwards it was shown (Paget, Druitt, Kirkes. Good- 
fellow, &c.) that not only thrombosis in veins, with or without inflam- 
mation, but also inflammatory or degenerative deposits on the heart's 
valves, may give off emboli or floating masses, which may obstruct the 
arteries of the lungs, liver, brain, or other organs, causing atrophy, or 
irritation and inflammation. The septic degeneration of the debris of 
such clots may also contaminate the blood, — causing septicaemia or 
ichorhaemia. 

Emboli are, apart from their origin, chiefly arterial or venous in 
their locality. The arteries most often so obstrupted are, those at the 
base of the brain, the internal carotids, the femoral, brachial, splenic, 
renal, external carotid, and mesenteric arteries. One obstruction is 
apt to be the source of others. Cessation of the pulse of the arteries 
in a limb is an early positive sign. Gangrene is usually the last and 
fatal event if an extremity be involved. 

When the right half of the heart has received an embolus, and the 
pulmonary artery is obstructed, collapse of the lungs, partial or entire, 
follows. Pleurisy, hemorrhage, or bronchitis may occur also, Or, the 
symptoms may be, great anxiety and dyspnoea, with reduction of the 
temperature of the body. A systolic murmur may be heard on aus- 
cultation ; the rhythm of the heart becomes irregular ; and pulsation 
of the jugular veins may be noticed. Giddiness may be present, with 
blueness and oedema of the hands, feet, or both. Death occurs in much 
the greater number of cases of embolism. 

Where emboli have become broken up and decomposed, septicaemia 
results — commonly known as pyaemia; as before explained. The tem- 
perature in this disease is commonly high ; from 106° to 107° in the 
evening exacerbation. 

For treatment of embolism, without septicaemia, our only resources 
are rest, support by food and stimulants, and alleviation of nervous 
disturbance by opiates. 

ANGEIOLETJCITIS. 

Definition. — Inflammation of a lymphatic vessel. 

Causation. — Any local irritation or injury may cause a neighboring 
lymphatic to inflame ; but it is especially apt to follow a poisoned 
wound. Erysipelas may be attended by it. Dissecting wounds almost 
invariably produce it. In my own person this has happened several 
times ; once, the absorbed matter so affected the whole trunk of the 
lymphatics proceeding from the right thumb, as to cause a large 
abscess in the axilla, with a severe illness. This experience has 
enabled me to arrive at a somewhat clear conclusion as to the nature 
and consequently proper treatment of " dissecting wounds" which, 



334 DIATHESES. 

from want of care in prevention (by sucking and washing the part 
thoroughly at the moment of the injury) have been allowed to bring- 
on local and lymphatic inflammation. 

The pathognomonic sign of angeioleucitis is a distinct and somewhat 
elevated red live up the limb, or the part, with tenderness well- 
marked throughout its course. 

That produced by a dissecting wound is, as I have proved, an 
inflammation, which may be quite sthenic ; not necessarily " typhoid," 
as some have imagined. I am sure that the free application of foreign 
leeches to the hand, and a large dose of Epsom salts, aborted one 
attack, which was threatening to be severe. Of course some cases 
may be asthenic or typhoid ; but of all that I have seen, with three 
examples in my own person, none have been so. 

In ordinary angeioleucitis, the application of a light muslin or linen 
rag wet with lead-water and laudanum, allowed to evaporate, will be 
suitable. The part must, also, of course, be entirely at rest. 

WHITLOW. 

Synonym. — Felon. 1 The frequency with which this comes under 
every physician ? s notice makes it a proper topic for brief remark here. 
A felon or whitlow is a suppurating inflammation of one or more of 
the fingers. Yelpeau's subdivision of its varieties is as good as any , 
into : 1. Sub-epidermic. 2. Subcutaneous. 3. Fibro-synovial. 4. Peri- 
osteal. The first is trifling, the second may be severe for several days, 
the third may cause great suffering for two or three weeks and lame 
the hand, the fourth threatens the loss of a phalanx or of the finger. 

Many practitioners always divide an inflamed finger down to the 
bone as soon as it is manifest that the inflammation is sure to pro- 
gress. Yelpeau advises early incision only in that form in which 
periostitis exists. I believe he is right. The only difficulty is in making 
sure of the diagnosis. But I would, upon experience, lean towards 
the doubt, and wait for suppuration unless satisfied of the deep-seated 
nature of the attack. 

Leeches sometimes, water-dressing or irrigation, and poultices, com- 
prise the rest of the treatment. 

ONYCHIA. 

Synonym. — Paronychia. Inflammation followed by suppuration 
or ulceration about the root of the nail. Injuries generally bring it 
on, but cachectic constitutions are most liable to it. The nail may 
become loosened, so as to be removable. Much more rarely, the last 
phalanx of the finger or toe suffers necrosis. Poultices, lime-water, 
solution of sulphite of soda, &c, with rest to the part, in bed if it be 
a toe, comprise the usual means of treatment. 

ONYXIS. 

This is commonly, but improperly, called in-growing nail. The 
great toe is its much most frequent seat. It is an inflammation of 

1 The term paronychia is best restricted to cases occurring near the nail. 



CARBUNCLE — ADDISON S DISEASE. 335 

the soft parts near the nail; their swelling pressing upon the latter; 
not the nail growing toward or into the flesh. The difference is im- 
portant in reference to the treatment. For this, the patient must re- 
main in bed, or at least avoid walking, until the inflammation of the 
toe subsides. Then the ulceration may be treated, if extensive, with 
lime-water, solution of sulphate of copper, <fcc. ; and, if fungous pro- 
trusion of indolent granulations (proud flesh) exists, with touches of 
solid nitrate of silver every day or two. After this, or in milder cases 
from the first, a little strip of lint or cotton smeared with simple cerate 
or cold cream should be gently and carefully worked, with the back 
of a small knife blade, or the head of a large needle, in behveen the 
flesh and the nail, to be left there. Adhesive plaster may be put on 
so as to draw the flesh away from the nail, which is first trimmed 
closely and smoothly at its edge. Then paint the parts thicMy with 
collodion. This makes an artificial cuticle; the cure will generally 
be rapid and complete, unless in malignant disease of the matrix of 
the nail itself. I do not think that the nail need ever be removed. 

CAKBTJNCLE. 

Synonym. — Anthrax. Though approaching or passing the bounds 
of surgery, the same reasons will excuse a word about this affection also. 
The causes of it, as well as of furunculus or boil, are undetermined. 
Boils and carbuncles are positive opprobria medicinal ; no one knows 
how to prevent them or to stop their continued recurrence. I have 
known ten or twenty boils or carbuncles to follow each other, in spite 
of purgatives, low diet, strong diet, tonics, refrigerants, alteratives, 
and even the sulphites, all tried in turn. 

Carbuncle is a subcutaneous phlegmonous inflammation, more ex- 
tensive than a boil, and attended by a larger sloughing of connective 
tissue under the skin ; with much more pain and constitutional dis- 
turbance. It may even threaten life. The swelling is round, and 
flattened on its elevated surface. Kedness may exist for some dis- 
tance beyond it. 

In the treatment of carbuncle, besides emollient poultices or warm 
water dressing under oiled silk, all surgeons agree that, at an early 
period, the tense skin must be divided or removed, to allow the extru- 
sion of the slough and detained pus. Many make a crucial incision, 
quite across the tumor each way. Yelpeau prefers a radiated incision ; 
from the centre in several directions, extending a little beyond the 
circumference of the tumor. Probably no method is better than to 
congeal the part with Eichardson's or some other spray-producer, 
with rhigolene or ether, and apply caustic potassa freely, until the 
whole top of the carbuncle is deeply blackened. Poultices, &c, will 
of course be afterwards required. Generally the patient requires to 
be supported by good diet, and, perhaps, tonics. 

ADDISON'S DISEASE. 

Synonym. — Melasma Supra-renal is. Hardly any clinical asso- 
ciation of morbid changes is more obscure in its pathology than this. 
A bronze-like discoloration of the skin comes on gradually, preceded 



336 DIATHESES. 

and accompanied by symptoms of anaemia and debility (muscular 
weakness, feebleness of the heart's impulse and pulse at the wrist, 
short breath upon exercise, impaired digestion, sometimes dimness of 
vision) ; after lasting from less than one year to four or five years, 
death occurs, and the only characteristic lesions are found to affect 
the supra-renal capsules. Dr. Wilks has been almost as prominent 
as the late Dr. Addison in the study of this disease. Dr. Greenhow 
has lately written an excellent monograph (Lectures) upon it. 

It is manifestly a cachexia. Probably both the supra-renal capsular 
disease and the affection of the skin (olive-greenish darkening, mu- 
latto-like, or like bronze without the gloss) depend upon the consti- 
tutional state. Perhaps caries of the vertebrae (scrofulous), which 
has been sometimes observed, may, by involving the ganglia in dis- 
ease, thus produce the complex errors of nutrition, superficial, and 
general. Dr. Wilks describes the appearances of the supra-renal 
capsule as resembling those of scrofulous lymphatic glands ; a larda- 
ceous material being deposited, which afterwards softens into a putty- 
like mass (grayish translucent material with yellow cheesy nodules), 
or undergoes drying into a chalky concretion. The disease is fatal 
always, at last. Besides hygienic management, and perhaps iron or other 
tonics, little treatment is recommended for it. Dr. Greenhow asserts 
decided advantage to have followed the use of a combination of gly- 
cerin, in two drachm doses, combined with fifteen or twenty minims 
each of spirit of chloroform and tincture of chloride of iron. 

GOITRE. 

Synonym. — Bronchocele. In low and narrow valleys of the Alps, 
Andes, Himalayas, or other mountains, but especially often in Switz- 
erland, whole families and village populations are affected with (con- 
genital or early) enlargement of the thyroid gland, which sometimes 
becomes enormous. A stranger, upon a residence for a few months 
in one of the same localities, may be likewise affected; and, after 
leaving it for a high and open, salubrious country, may recover from 
it. Associated often, but not always, with this affection of the neck, 
is cretinism ; a condition of bodily and mental weakness, stunting and 
deformity, most lamentable. 

Occasionally, in any locality, a case of goitre or enlargement of the 
thyroid gland to a slight or moderate degree may be met with. I do 
not remember to have seen more than half a dozen cases of it in 
Philadelphia ; none of them severe. 

Causes of goitre, among the mountains, are believed to be, 1. Ex- 
cess of magnesia and lime in the drinking water ; 2. Dampness and 
deficiency of light ; 3. Other unfavorable hygienic conditions ; among 
them, frequent intermarriage of near relations in a stationary popu- 
lation. 

In the treatment of goitre, iodine has had the reputation of a spe- 
cific. It is not, however, infallible. Dr. GUggenbuhl many years 
since proved that the best management for goitrous and cretin chil- 
dren was to remove them from their valley and village homes to high, 
airy, and light situations, and there to give them good food, exercise, 
and other appliances of a health-producing regimen. 



SKIN DISEASES — EXANTHEMATA. 337 



DISEASES OF THE SKIK 

As a clinical classification of cutaneous disorders, most convenient 
both for description and treatment, I prefer the following : — 

Exanthemata. Pustulae. Tubercuhe. 

Papulae. Squamse. Haemorrhagiae. 

VesiculaB. Maculae. Neuroses. 

Bullae. Hypertrophic. Parasitica?. 

Syphilida. 

EXANTHEMATA. 

In these, there is active congestion or hyperaemia of the " derma" 
or true skin. Besides scarlatina, measles, and erysipelas, already 
considered, this order contains erythema, urticaria, and roseola. 

Erythema. — Superficial, circumscribed red patches, of variable 
shape and size, on the face, trunk, or limbs, not painful nor very sore, 
characterize this. Its causes are, all moderate but somewhat con- 
tinued irritants to the skin. Its duration is generally but for a few 
days or a week or two. No fever attends it; nor is it either conta- 
gious or dangerous. 

Varieties 1 of erythema are, erythema fug ax, or fleeting ; erythema 
intertrigo, from friction of two surfaces of the skin, as in not well 
cleaned children; erythema rheumatica, occurring now and then in 
rheumatic fever ; erythema pernio, or unabraded chilblain ; and ery- 
thema nodosum, on the legs, with rounded node-like prominent red 
patches, somewhat more inflamed than in the other forms. 

Treatment of erythema must depend upon its cause more than 
upon its particular form. The stomach and bowels may need atten- 
tion, with the use of antacids and laxatives ; especially magnesia and 
rhubarb or Rochelie salts, or the citrate of magnesia. 

Local applications may be, finely-powdered starch or arrowroot, 
dusted on, dry ; cold cream (unguent, aq. ros.) ; lime-water and oil, 
equal parts (olive, or lard oil) ; ointment or glycerole of zinc [F. 177, 
178, 179, 180] ; glycero-cerate of lead; or glyceramyl [F. 148]. 

For erythema 'pernio, or frost-bite of mild degree, astringents are 
serviceable ; as bathing the feet in tepid infusion or decoction of oak- 
bark, or solution of alum ; or applying cerate or glycerole of carbo- 
nate of lead. Some recommend cabbage leaves. 

Urticaria. — Nettle-rash. Elevated round or oval, red or white, 
patches or wheals characterize this. They may come and go in an 
hour, over the arms, trunk, or legs. Much burning, stinging, or itch- 
ing attends them. The affection commonly lasts only a week or two ; 
sometimes it is chronic and tedious. 

Disorder of the stomach (as from unwholesome food) is rather more 
likely to cause nettle-rash than any other kind of eruption. Mild 
purgatives, especially salines or the antacid magnesia, with or without 

1 Here, as in other affections of the skin, only the principal varieties are 
named. Wilson makes sixteen varieties of erythema. 
29 



338 SKIN DISEASES. 

powdered charcoal, are commonly suitable for it, after a dose (two or 
three grains) of blue mass. Light diet is necessary. Vinegar and 
water, glycerin and rose-water, or the starch-powder, etc., mentioned 
for erythema, will answer for local applications. Much use of cold 
lotions should be avoided, lest the eruption be over hastily repelled, 
inducing gastric, hepatic, or other internal disturbance instead. 

Roseola. — Bright, and yet generally dark red, damask rose-colored 
patches, irregular in shape and of various size, over any parts of the 
body, without much if any fever, belong to this affection. It is gen- 
erally of but a few days' duration. Sometimes a certain amount of 
resemblance is presented by it to scarlet fever or measles ; but the 
peculiar sore-throat of the former, and the catarrhal symptoms of the 
latter, are wanting. 

Scarcely any treatment is called for in roseola ; no local application, 
as the rash is but slightly irritating ; and only such medicine as the 
general condition of the patient may indicate. 

PAPULA. 

These, pimply eruptions, involve depositive inflammation of the 
skin ; which is raised in small, red, round, or conical points or minute 
tubercles, not very hard, and often, though not always, transitory. 
Papular affections are Lichen and Strophulus. 

Lichen. — Pimples numerous, but of small size ; red, and more or 
less heated and irritated. The principal forms of it are Uche?i sim- 
plex, common on the face, neck, etc., lichen tropicus, or prickly heat, 
and lichen agrius. The last named is the most inflamed and painful ; 
sometimes quite severe. Lichen simplex, though mild, may be ob- 
stinate in its persistence ; annoying ladies, sometimes, by remaining 
long on the face. In lichen tropicus, from which children, especially, 
often suffer in summer time, the eruption is not prominent, but the 
sense of irritation is very unpleasant. 

Lichen agrius may become, in violent or neglected cases, a scabby 
confluent eruption, with cracks or fissures, and a serous, perhaps 
purulent discharge. This is not, however, very common. 

Treatment. — Even for the simple form, and still more for 1. agrius, 
constitutional alteratives are likely to be needed, doing more good 
than local applications. In 1. tropicus, starch-powder, glycerin and 
rose-water, or glyceramyl, or weak lead-water will suffice, without any 
medicine. But in the other forms, rectification of any error of balance 
in the system must first be made. The plethoric must have low diet ; 
the anaemic, lean meat, perhaps bitters, aromatic, sulphuric, or nitric 
acid, or iron. Costiveness must be overcome, as, by cream of tartar 
and sulphur, rhubarb and aloes, or other mild but decided laxatives. 
Blue mass may be given, a grain twice daily for two or three days. 
Then, arsenic may be prescribed; of Fowler's liq. potass, arsenit., 
three drops twice daily at first, increased every week one drop until 
ten twice daily have been taken ; omitting the remedy if headache, 
nausea, diarrhoea, or puffiness of the face occur. 

In lichen agrius, rest in bed may be required ; with lime-water and 
oil dressing, or poultices of bread and milk, or flaxseed meal, or slip- 
pery elm bark powder, glyceramyl, etc. 



vesicul^. 339 

Strophulus. — Red gum is a common name for this papular eruption 
of infancy. Indigestion, reflex irritation from dentition, and over 
thick clothing or living in hot rooms, produce it. The eruption is uot 
severe, consisting of many small red pimples, close together, and often 
nearly all over the body. Attention to the stomach and bowels is 
necessary. Lancing the gums is 'proper (all authorities to the con- 
trary notwithstanding) if they be swollen, tender, or so tense as 
evidently to distress the child. To the rash, only very soothing appli- 
cations should be made, as starch-powder, ointment of oxide of zinc 
[F. 181], or glyceramyl. Care with the diet, if fed instead of being 
nursed, is of course also of great importance. 

VESICTJL.E. 

These are effusive inflammations of the derma; characterized by 
numerous and small water blisters; the smallest are sudamina ; the 
largest, herpes ; eczema having vesicles of intermediate size, and 
scattered. Sudamina are met with in low fevers, consumption, &c, 
mostly when perspiration alternates with the febrile state in an 
enfeebled system. 

Eczema. — This has been the subject of much disputation ; as to 
whether it is a disease per se, going through stages not only of effusion, 
but also of incrustation, suppuration, desquamation. Arc. ; or, only a 
phase of cutaneous irritation and inflammation, called vesicular, 
whatever its cause, and eczematous to distinguish it from the herpetic 
eruptions. Unable to decide this question with positiveness, I am 
satisfied, nevertheless, that, while the eczematous vesicular eruption 
admits of very distinct description and recognition, it may come from 
or after a papular rash, and may in the same case be transformed (or 
progress) into a pustular or scabbing disease. 

Eczema simplex, rubrum, infantile, and impetiginodes are its prin- 
cipal varieties. Besides others named in the books, there are also 
eczema solare, from heat, and eczema mercurialis, from the impression 
of mercury on the system. The simple form has but little inflamma- 
tion ; but there is always some soreness, and the vesicles may run 
together and break, oozing serum or lymph, or scabbing lightly. 
Eczema rubrum is more inflamed, with redness, heat, and some tume- 
faction. Crusta lactect or milk crust is a name often given to eczema 
infantile of the nursing time. It affects the face, sometimes very 
unpleasantly; scabbing, running and cracking all over it. E. impeti- 
ginodes appears to be an intermediate stage, or transition, between 
eczema and impetigo ; water blisters appearing at first, and pustules 
afterwards. 

Treatment. — An inflammatory state attends the eczematous erup- 
tion, nearly always ; especially in e. rubrum and advanced crusta 
lactea. Saline laxatives, diuretics and diaphoretics (Rochelle salts, 
bitartrate of potassa, citrate of potassa, &c.) are often called for, 
perhaps to be repeated in moderate doses. Light diet is, in like case, 
proper. In children, small doses of calomel occasionally do good. 
Locally, weak lead-water when there is no scabbing ; lime-water and 
oil when there is great irritation ; decoction of bran ; flaxseed infu- 
sion with bicarbonate of soda Qj in f§iv) ; glyceramyl ; glycerin with 



340 SKIN DISEASES. 

rose-water ; carbonate of lead cerate ; ointment of oxide of zinc ; these 
are among the many applications used with advantage. The whole 
bath, tepid or slightly warm (never hot) two or three times a week, 
will be beneficial. In chronic eczema, the "Turkish" or dry, hot 
air bath (130° to 150°) is highly recommended by some. 

Chronic eczema acquires alterative treatment internally. Arsenic 
is the alterative, par excellence, in obstinate cutaneous affections. 
Its peculiar action on the skin tends to displace the morbid process, 
and thus to restore, after its own transient influence is withdrawn, 
healthy nutrition and reparation. Five drops of Fowler's solution 
may be given at first, twice daily, increased gradually until the dose 
amounts to ten drops ; sometimes even more. The medicine must be 
intermitted if the head, stomach, or bowels show its decided action. 
In case of its failure, particularly where syphilitic taint is possible, 
Donovan's solution (liq. arsenici et hydrargyri iodidi) may be given ; 
three drops at first, cautiously increased. Scrofulous or otherwise 
feeble children may need cod-liver oil. In crusta lactea, or eczema 
infantile, the mother or nurse must be instructed not to burden the 
child with clothes, nor keep it in an overheated room. Daily bathing 
is particularly important to an infant suffering with such an eruption. 

Herpes. — This has larger, more separated and less numerous 
vesicles than eczema ; it is less apt to be chronic. Varieties : herpes 
phlyctenodes, herpes zoster, and herpes circinatus. The first is the 
most frequent; receiving also local names, according to its seat: as 
h. labialis, prceputialis, &c. Herpes labialis is commonly called 
" fever blisters." 

Herpes zoster is singular, but not very common. Half of the body, 
about the waist, is covered with vesicles, on an inflamed red surface. 
Sometimes neuralgic pains, quite severe, attend it. It generally affects 
the right side. Its duration is but for a week or two ; unless in the 
feeble or old, in which it may be followed by ulcerations of a tedious, 
perhaps dangerous character. 

Herpes circinatus is distributed in circular patches or rings. 
Minute vesicles appear around the circumference. By these, and the 
absence of the microscopic vegetation, and less disposition to 
chronicity, it is distinguished from tinea tonsurans, or true conta- 
gious ring-worm. Herpes iris, of writers, is an aborted h. circinatus; 
the rings being incomplete. 

Herpes rarely appears in old persons; often in children and ado- 
lescents. All causes of irritation of the surface of the body may cause 
it ; as febrile or catarrhal attacks, stimulating diet, violent exercise, &c. 

For the treatment of herpes, the plan stated for eczema is, in 
principle, here also suitable. Cucumber ointment may be added to 
the applications recommended. Herpes zoster requires confinement 
to bed. The severe pains, in this, may call for anodynes. Herpes 
labialis is sometimes very annoying, especially to ladies. Pure 
cologne-ivater applied at the very start, may abort the vesicles. 
Magnesia powder is used by some to dust about the lips. Calomel 
ointment is recommended when the eruption is chronic, coming out 
in successive crops. 



BTJLL.E — PUSTULE. 34 L 



BULLE. 



These are eruptions of large vesicles. Pemphigus and Rupia are 
the most distinct. 

Pemphigus. — Bullae of a circular or oval shape, from half an inch 
to two inches in diameter, and flattened. They may be distributed 
over any or all parts of the body. Fever, sometimes considerable, 
precedes and accompanies the eruption. I have seen it a very serious 
illness. After the vesicles mature, they burst, or dry away, leaving 
thin brown scabs. Ulceration may occur, but it is not deep or ob- 
stinate, unless in a particularly unhealthy constitution. The duration 
of pemphigus is from one to three weeks, or more in bad cases. 
Pompholyx is the name given to a rare variety of pemphigus, in which 
the space continuously covered by bullae is large, and there is little or 
no fever. A fly-blister causes artificial pompholyx. 

Pemphigus is not usually considered to be contagious. One family 
came under my notice, however, in which five individuals were attacked 
by it, partly in succession, after travelling. It was difficult in that 
case not to suppose contagion. 

In the treatment of pemphigus, gentle refrigerant laxatives at first, 
diuretics and diaphoretics next, and, often quite early, tonics and sup- 
porting regimen are called for. In one case I was obliged to stimulate 
quite freely ; the eruption being as confluent as in any case of small- 
pox, and prostrating, like an extensive burn. No local applications, 
other than the mildest lotions or unguents, will be suitable. The 
early puncture of each bullae with a small needle is recommended ; 
but the raised cuticle must not be removed. 

Rupia is probably but a modification of pemphigus : with smaller 
blebs or bullae, followed by thicker conical scabs, of dark color ; after 
whose removal ulcers are left, which may be weeks in healing. Eupia 
simplex is the variety in which the scabs are low and the ulcers 
slight ; rupia prominens in which they are elevated into irregular 
cones ; rupia escharotica, when the ulceration is deep and extended. 
Syphilitic rupia is quite common ; but every case of rupia is not, by 
authorities, admitted to be syphilitic. My observation goes to sustain 
this non-admission. 

Treatment of rupia requires to be, generally, tonic and alterative. 
Quinine, cod-liver oil, and iodide of potassium, with good but simple 
diet, are apt to be wanted for it. 

PUSTULE. 

Suppurative inflammation of the skin (excluding smallpox, furun- 
cle, and carbuncle, as well as the malignant pustule or charbon of 
the French, a rare affection said to be received from cattle) appears 
in the two forms Ecthyma and Impetigo. 

Ecthyma. — Large, round, prominent pustules, upon any part of the 
body, not numerous ; ending in thick dark scabs, followed by slight 
(or in cachectic states, obstinate) ulcerations. Ointment of tartar 
emetic, or pure croton oil, or other strong cutaneous irritants, will 
produce it. Often, however, especially in syphilitic persons, or after 

29* 



842 SKIN DISEASES. 

acute fevers, &c., it occurs without local exciting cause. Sometimes it 
is chronic. 

In treatment the causation is of great importance. If a local irri- 
tant produce it, local emollients, perhaps with general refrigerants, are 
to be used for its relief. Otherwise, diet, and balancive measures will 
be more in place : tonics for the feeble, purgatives and light regimen 
for the plethoric, &c. 

As an eliminant and refrigerant in both ecthyma and impetigo (as 
well as rupia) I have found apparent benefit from the use of a pre- 
scription employed by Dr. Anderson of Scotland ; equal parts of 
wine of colchicum and wine of ipecac., say ten drops of each, thrice 
daily [F. 182] . Arsenic is called for in obstinate cases, as in other 
diseases of the skin ; Fowler's or Donovan's solution, in small doses 
carefully increased. 

Impetigo. — Small and somewhat numerous pustules : varieties, 
impetigo figurata and impetigo sparsa. I. figurata is most common 
on the face, in circumscribed clusters of pustules, which may become 
confluent and scab. To this, in children, as well as to eczema infan- 
tile, the name of crusta lactea is given by authors. I. sparsa has the 
pustules scattered over more or less of the whole body. 

Treatment. — When much irritation or inflammation exists, lead- 
water, glyceramyl, ointment of oxide of zinc, lime-water and olive 
oil, flaxseed tea and bicarbonate of soda, light poultices of flaxseed 
meal, slippery elm bark, or bread crumb, are to be applied. Daily 
use of castile soap and water is serviceable. Purgatives may be 
needed. Diet must be according to the general condition of the 
patient. Impetigo may affect the hairy scalp ; if so, the hair must 
be cut and kept very short. Colchicum and ipecac, may be given in 
acute cases ; arsenic in those which become chronic. 

SQUAMA. 

Scaly diseases are, Lepra (Alplws of Wilson), Pso?"iasis, Leprosy 
of the Hebrews, Spedalsked or Norwegian leprosy, Pityriasis, and 
Ichthyosis. 

Lepra. — Always chronic, and very difficult to cure. Not regarded 
as contagious, though I have seen it occur successively in four persons 
in immediate contact (an infant at the breast, its wet-nurse, another 
infant suckled by her, and her husband). It is characterized by red 
desquamating patches, of various sizes, approximating to a circular 
shape, on any parts of the body ; especially on the arms and legs. 
Besides syphilitic lepra, its varieties are lepra vulgaris, with small 
patches and few thin scales, and lepra inveterata (alphos diffusus of 
Wilson) where they are large and desquamate extensively. 

In both, the margin of the patch is the highest, reddest, and most 
squamous part. 

Psoriasis. — Described under the names of ps. vulgaris, gyrata, 
and inveterata, psoriasis differs mainly from lepra in the irregular and 
varied forms of the desquamating patches ; and in the absence or less 
degree of depression near their centres. Wilson's view that psoriasis 
is only a kind of chronic eczema, does not seem to me to accord with 
the facts of its ordinary history. It is sometimes hereditary ; as is 



SQUAMA. 343 

also lepra. No disease of the skin is so hard to eradicate, unless it 
be ichthyosis. 

Treatment, — For lepra and psoriasis alike, all sorts of alterative 
agencies, local and systemic, are, if cautiously used, suitable for 
tentative practice. Our object is, to obtain the making of a new 
skin, unaffected by the morbid habitude of nutrition. Frequent 
bathing should be practised. Tar ointment, citrine ointment, oint- 
ment of sulphuret of potassium [F. 183J, &c, may be applied. 
Arsenic, and the iodide of arsenic and mercury (Donovan's) should 
be given, carefully, but repeatedly, through long periods. Other 
medication must depend upon the conditions of each case. 

Ichthyosis (Fish-skin disease), — This is rare ; I have seen but one 
case of it. Hard, thick, dry scales form, continuously, over a part, or, 
sometimes, nearly the whole surface of the body; without much red- 
ness, soreness, or even itching. It is congenital and incurable. 
Frequent and thorough ablutions, and mild emollient applications, are 
palliative to it. 

Pityriasis. — This is a chronic affection in which very numerous 
small white scales (dandriff) form upon the skin, particularly the scalp 
(p. capitis). Some redness, and often a good deal of itching, may 
attend it. It is difficult of cure in many cases. If it be upon the 
head, keeping the hair short, and washing daily with castile soap, fol- 
lowed by a spirituous lotion, or glycerin and rose-water, will do the 
best for it. Cleanliness and frequent bathing in tepid, cool, or, if the 
vigor of the system permit, cold water, are of essential importance in 
all cases. 

The term 'pityriasis versicolor is sometimes applied to an epiphytic 
disease (*. e., one connected with a vegetable parasitic growth], better 
called chloasma versicolor. 

Spedalsked is a disorder only known in Norway and Sweden ; espe- 
cially among the fishermen. Accounts of it are given in medical 
journals and books; 1 but the mere reference to it will suffice here. 
(See Elephantiasis Grcecorum.) 

Leprosy of the Bible (Lepra Hebraeorum) is of great historical 
interest. 2 It is still recognizable in the East, though not frequently 
met with. I saw a case of it in Alexandria, in 1859. 

In the Book of Leviticus, three varieties of leprosy are described : 
dull or darkish white " freckled spots,'' — 'dusky or shadowed, — and 
bright white (bahereth lebhana), the worst of all. Tsorat (whence 
psora, and sore) or malignant disease, was applied to th£ last two 
only. Lepra is an early Greek synonym of this term. 

Mason Good thus describes the old leprosy : "A glossy, white, and 
spreading scale upon an elevated base ; the elevation depressed into 
the middle, but without change of color; the black hair on the patches, 
which is the natural color of the hair in Palestine, participating in the 
whiteness, and the patches themselves perpetually widening their out- 
line." 

In favorable cases, after spreading over much of the person, though 

1 See Brit, and For. Medico-Chirurg. Rev., 1850, p. 71. 

2 See Neligan's Treatise on Diseases of the Skin, edited by Dr. Belcher 
(Philadelphia ed., 1866, p. 289). 



344 SKIN DISEASES. 

without ulceration, the disease would die out ; the scales would dry- 
up and gradually disappear. In bad cases, ulceration would occur, 
with extensive sores, as well as desquamation. Then the leper was 
made an outcast, and treated as one dead ; " unclean for life." 

Not only the books of Moses, and others of the Bible, but also 
Hippocrates, Galen, and Oelsus (under the names aivxq, and airfpa 
tevxri) speak of ancient leprosy as a white scaly disease. It thus 
differs decidedly from either kind of elephantiasis. 

MACTJUE. 

Ephelis, Vitiligo, and Chloasma may be included under this term ; 
perhaps better, under that of Decoloration es. 

Ephelis; lentigo. — Sunburn and freckles best correspond with 
these names ; which, however, are by some authors extended further. 
Neither are of importance unless in regard to appearance. For the 
removal of freckles (which often disappear spontaneously with time) 
or the yellowish-brown spots called chloasma, or melasma, all applica- 
tions may fail ; dilute nitro-muriatic acid (fifteen to thirty drops in an 
ounce), left for some time in contact with the discolored spot, is more 
likely than anything else to take effect. 

Vitiligo. — Literally, veal-skin. Unnatural whiteness from deficiency 
of coloring matter. When universal over the body (nearly always 
then congenital) it is albinismus. We see albinoes, sometimes fami- 
lies of them, occasionally, in all the races of mankind ; as well as 
among the lower animals. Leucopathia, or white disease, is a name 
given by some writers to both the general and the local affection. 

When local, vitiligo is seen mostly in rounded patches or spots, 
which slowly increase in size, though without regularity of shape. 
The head, chest, back, and thighs are the most frequent seats of them. 
The hairs on the parts involved become white ; or fall out, causing 
baldness — calvities, or alopecia. 

Treatment, for vitiligo, must be, first, general, for improvement of 
nutrition in the whole system, — and then local. Very hard it may be 
to cure the affection, although its importance is chiefly for appear- 
ance ; no danger attends it. Tannic acid and oil of turpentine are 
the preferred local applications for it. Total albinismus is quite in- 
curable. 

Chloasma (pityriasis) versicolor will be spoken of under Parasitica?. 

For alopecia, baldness, or premature loss of the hair, very many 
remedies are in vogue. Shaving the head repeatedly (i. e., after an 
illness) may often save the hair. Stimulating applications sometimes 
help and sometimes hurt the case [F. 185, 186]. 

HYPERTROPHIC. 

Morbid excesses of development of the skin or tissues connected 
with it, are thus named ; Ncevus, Clavus, Verruca, Elephantiasis 
Arabum. 

Naevus. — (Mole, mother-mark.) This is always congenital. Dis- 
coloration and elevation of the part exists, with abnormal development 
of the capillaries and small veins of the skin ; making a small, commonly 



HYPERTROPHIC. 345 

flat, vascular enlargement. It is seldom more than an inch in diameter. 
Erectility sometimes belongs to the vessels of naevus. 

Caustic, the ligature, the knife, and vaccination of the part, have all 
been employed for the removal of such formations. They may leave 
scars worse than the mole ; the operation ought to be exceptional. I 
have known it, performed early in infancy, to be quite successful. 

Verruca. — Wart. A hypertrophy of the skin, with great develop- 
ment of the cuticle especially, upon a small surface ; such is a wart ; 
of which no one needs a further description. Some persons and fami- 
lies are especially liable to them ; why we cannot say. 

Treatment. — Strong nitric acid ; chromic acid ; caustic potassa ; 
and in slight cases nitrate of silver, carefully applied only to the wart, 
after paring off nearly all the insensitive portion of it, will always, at 
least after repetitions, remove warts. 

Clavus. — Com. Most persons are well acquainted with this sort of 
localized hypertrophy of the skin of the foot, from irritating friction 
and intermittent pressure. Prevention is more easy, by far, than cure. 
Corns are either hard or soft ; the latter may become inflamed ; the 
former hurt only under decided pressure. 

Pare a hard corn with a sharp knife or razor, closely, but not so as 
to hurt or draw blood. Soak the foot then in warm water for five or 
ten minutes, and pick out carefully the centre or u core." Two thick- 
nesses of adhesive plaster, with the centre cut out (making a ring) 
should be put over the corn ; and a third piece, the centre not cut 
out, placed upon it and them. 

Soft and inflamed corns require removal of all pressure for a while, 
and poulticing, <fcc, first ; then the above treatment. 

Condylomata. — These are fleshy tumors or out-growths, more or 
less hard and wart-like sometimes, in other cases soft ; of syphilitic 
origin often, but not always. Especially apt are they to occur about 
the anus, prepuce, and vulva. 

To remove such formations, if they be small and hard, nitric acid, 
pure, may be used, with care, to limit its contact to the part to be 
destroyed. When large, and soft, if troublesome enough to require 
destruction, the ligature is generally preferred. It may be, with a 
needle, passed through the centre of the mass, and then drawn and 
tied tightly about the base. 

Elephantiasis Arabum. — Bucnemia Tropica of Wilson ; "Barba- 
does Leg." 

Enormous enlargement of the leg, scrotum, or neck, most often met 
with in warm countries, but occasionally anywhere, is thus called. 
Hard and nearly immovable, the parts become at last. The connec- 
tive tissue as well as the dermoid texture proper is greatly hypertro- 
phied. Impediment to the return of surplus material of nutrition by 
the lymphatics is the probable pathogenetic cause ; the nature of the 
impediment has seldom been discerned. 

Ligature of a large artery is asserted to have arrested the growth 
of elephantiasis. No other treatment appears to be worth trying 
for it. 



346 SKIN DISEASES. 



TTJBERCULA. 

Acne, Molluscum, Lupus, Elephantiasis Grcecorum, Framboesia, 
Keloid. 

Acne. — Tuberculous elevations, from inflammation of the skin 
around sebaceous follicles, in which the secretion is detained, or is of 
a morbid character, — are called acne. Three varieties may include 
all those named by authors ; viz., acne simplex, acne pustulosa, and 
acne rosacea. 

Acne simplex or punctata has small and moderately red, rather hard 
tubercles, on the face principally. When very hard and chronic, it 
may be called acne indurata. Black points commonly mark the ob- 
structed follicles. Acne pustulosa reaches a more mature suppura- 
tion, and is often painful, especially if upon the scalp. 

Acne rosacea always affects the face ; usually in adults, and most 
often in high livers. A good deal of soreness attends the eruption. 
First, the pimples are hard, red, and small ; as they mature they grow 
somewhat larger ; finally a little sanguinolent pus escapes, leaving a 
small scab. Eose redness around the pimples, or patches of them, 
has given rise to the name. It is generally a difficult disease to cure, 
and very unsightly. Not unfrequently it is hereditary. 

Treatment. — Errors of digestion, brought on by gluttony or in- 
temperance, or more moderate imprudence, often cause acne. They 
must be rectified for its cure. Attention to the state of the bowels, and 
to the action of the skin generally, is indispensable. Saline cathar- 
tics are useful in plethoric cases. Various mineral waters are recom- 
mended — saline and sulphurous especially. The pustules, when they 
mature, should be carefully punctured with a needle, avoiding irri- 
tating disturbances. Solution of carbonate or bicarbonate of soda 0j 
in Oj) in water or flaxseed infusion, will be a good wash. Sulphuret 
of potassium, in lotion or ointment, is also advised ; or ointment or 
glycerole of nitrate or amide of mercury (hydrarg. ammoniat.) [F. 187]. 

Obstinate cases justify more decided alterative treatment ; as, the 
application, by a cotton tip upon a knitting needle, of a solution of 
corrosive sublimate, two to five grains to the ounce of water or alco- 
hol, washing it off in a few moments; or, similarly, of pure Goulard's 
extract (liq. subacetate) of lead, followed by spermaceti ointment, 
cold cream, or glycerin and rose-water. Iodide of sulphur ointment 
(gr. xv to xxx in ^j of lard) is also much praised. In acne indurata, 
when very ugly, acid nitrate of mercury (mercury and nitric acid each 
an ounce) has been applied, and sometimes blistering the face with 
cantharidal collodion. 

Molluscum. — Acute molluscum is a somewat contagious tubercu- 
lous eruption. The small tumors form without inflammation, increas- 
ing slowly, till they have almost the size and form of a currant, but 
without color, and nearly flat-based or sessile. They last from three 
to six months, either ulcerating finally and then shrinking away, or 
inflaming and sloughing off, leaving a pit or mark. Several crops of 
tubercles may succeed each other on the face and neck, in either adults 
or children, but especially in the latter. 

Chronic molluscum is of still longer duration ; is not contagious, 
and the tumors are pedunculated, i. e., each has a stem, in many cases 



TUBERCULA. 31*7 

at least ; they also become larger, and occur over different parts of the 
body. Neither form of mollusc um is common. It is proper to add that 
some authorities do not admit the contagiousness of the acute variety. 

Treatment of acute molluscum seems not to be to any great extent 
available. In chronic molluscum the tumors may be cut off at the 
peduncle, the divided point being then touched with lunar caustic. 

Lupus, — L. exedens and non-exedens. or 1. superficialis, serpiginosus, 
and devorans (Xeligan). Lupus superficialis is a rare disease, in 
which, most often on the cheek, a small, soft, sore, slow-gathering tuber- 
cle appears, which in time scabs, and ulcerates superficially, the scab 
and ulcer spreading for an indefinite time, and leaving behind them a 
permanent, whitish seam or scar. Irritation may make the tubercle 
very painful, and deepen the ulcer. It may last for years. 

Lupus serpiginosus exhibits one or more livid, red, indolent tumors 
on the face, head, or elsewhere, sore, heated, and itching. In the 
course of months they become filled with pus. and suffer an undermin- 
ing ulceration, which finally becomes an open, unhealthy-looking sore, 
forming upon it a hard, brown scab. Creeping from the edge of its 
original seat, in irregular rings, the disease extends, leaving behind it 
a depressed cicatrix. The same part may be again reached by its 
meandering progress. This is a very chronic affection, even of years' 
duration, without injuring the general health. 

Lupus exedens or devorans (noli me tangere or rodent ulcer) is 
characterized by continuous destructive ulceration of the skin, sub- 
cutaneous connective tissue, muscles, and other parts, at length in- 
volving even bones ; all following tubercles " rounded and dusky red/' 
on the nose, cheek, eyelid, etc. An ichorous discharge belongs to it : 
cicatrization follows it, sometimes (as in the previous form) to be 
again attacked. 

Young persons, from ten to thirty, are especially liable to lupus. 
Its progress is generally an affair of years, and it causes less suffering 
than its appearance would lead us to expect. Scrofula certainly, and 
probably syphilis, predisposes to it. It is very difficult to cure : some- 
times, at least, incurable. The obvious alliance with cancer has in- 
duced some authorities to place lupus in a class of affections called 
cancroid. It differs from cancer, however, in not involving the glands, 
nor contaminating the general system. Lupus is a comparatively rare 
disease. 

Iodine (as in Lugol's solution), cod-liver oil, and iron, internally, 
are commonly indicated in the treatment of lupus, especially the exe- 
dens. Fowler's or Donovan's solution may also, or each in its turn, 
be cautiously given. Chlorate of potassa has been suggested ; I do 
not know of its trial. Sea-bathing is likely to assist in the treatment. 

Locally, the animal oil of Dippel (made by dry distillation of harts- 
horn shavings) has a reputation in Europe for lupus superficialis as 
well as for 1. devorans. So have dilute solutions of chloride of zinc, 
nitrate of silver, nitric acid, kc. In the superficial variety, collodion, 
softened perhaps by adding ^ of glycerin, maybe painted lightly over 
the ulceration, every day or every few days. 

Excision is sometimes practised for the exedent form, to prevent 
disfiguration ; but the success of the operation is uncertain. So is 
that of strong caustics. Among these, nitrate of silver is preferred 



348 SKIN DISEASES. 

by most surgeons. Acetate of zinc, used solid for touching the ulcer, 
and applied every day or two, was much recommended by Neligan. 
He used also a lotion of the same salt, from three to five grains to an 
ounce of distilled water. Broadbent's new treatment for cancer, by 
injection of acetic acid) might be worth a fair trial in lupus. Its 
theory is very plausible. 

Elephantiasis Grsecorum .— Called by this name among the Greeks, 
probably because, as the elephant is a great and powerful animal, so 
is this a formidable disease. It was the leprosy of Europe in the 
middle ages ; for whose treatment many hospitals were built, and an 
order of Christian knighthood (of St. Lazarus) was established. 

It is characterized by many round tumors, from the size of a pea to 
that of an orange, livid, purple, yellowish or brownish, and soft ; on 
the face and other parts of the body. The skin around them thickens 
irregularly, giving a repulsive aspect. Ulceration occurs, deepening 
even to the bones ; all the organic functions suffer, and finally the 
mental faculties become enfeebled ; diarrhoea, and perhaps tetanus, 
precede death. 

This disease is probably identical with the spedalsJced of Norway, 
already named. Allied to it are radesyge of Norway, the morphie of 
Brazil, framboesia (raspberry disease) , Sibbens of Scotland, and Aleppo 
evil (button of Aleppo ; perhaps also the Ngerengere of New Zealand. 
Pellagra, of Lombardy, Spain, and France, is described by some as 
having a certain resemblance to it; but tumors do not belong to this 
disease ; in which, with a general cachexia, the skin becomes discol- 
ored and somewhat thickened, with arrest of its normal functional 
action. 

Treatment of elephantiasis and its allies must be upon the prin- 
ciples laid down for other serious cutaneous affections ; viz., to en- 
deavor to restore the balance of the general functions, whatever may 
be wrong ; whether that be by tonics, refrigerants, or purgatives, or 
other remedies acting upon the secretions ; also improving the nutrition 
and repair of the skin, by local and general alteratives. I am not 
acquainted with any specific remedy for either of the forms of disease 
just named. 

Keloid. — (Kelts, Kelois, Cheloid, Sclerema.) This is very rare. I 
saw one case of it, in a medical college ambulatorium, in 1860. 
Wilson, a few years since, stated that but twenty-four cases of it were 
upon record ; more have been reported upon since. An irregular, 
cicatrix-like, smooth reddish and whitish, corrugated excrescence, 
painful, with a stinging sensation, sometimes, but not always ; nearly 
in every case forming upon the front of the chest ; slow in growth, not 
ulcerating, and not tender to the touch. It is not unfrequently spon- 
taneously removed by absorption; but has not been shown to be 
amenable to treatment. Bayer advises constant firm compression. 

ILEMORRHAGLZE. 

Purpura is the only affection of the skin belonging under this head. 
On parts, or often the whole, of the body, appear round red spots, 
which become gradually of a dark purple color ; and then pass, as bruise- 
marks do, through green and yellow, till they disappear. They are ex- 



NEUROSES. 349 

travasations of blood into or upon the true skm, from its capillary 
vessels. The duration of each spot is about a week or ten days. 
Feverishness may precede, and prostration may accompany purpura. 
In bad cases, hemorrhages may take place from the mucous membranes, 
as those of the mouth, stomach, bowels, bladder, vagina, &c. ; pro- 
ducing, sometimes, even a fatal result. 

Purpura is by some improperly confounded with scurvy. Although 
extravasation of blood occurs in scorbutus, it also may happen quite 
independently of it. Deficiency of fresh vegetable food is not at all 
necessary to engender purpura; the causation and pathology of which 
clinical experience and chemical investigation have both failed to 
show. 

Treatment, — Although some assert plethora to be, as often as hy- 
dremia (anaemia), antecedent to purpura, my own experience goes 
with the ordinary view, that rather a tonic than a depletory treatment 
is generally called for in it. Excessive stimulation, it is true, will 
aggravate its symptoms. Mineral acids, as elixir of vitriol, and Hux- 
ham's tincture of bark, or quinine, &c, are much given. Oil of tur- 
pentine is also recommended. Neligan prescribed it in large doses ; 
even an ounce at once, with mucilage and an aromatic. This is beyond 
my degree of confidence in it ; but it is said that it acts generally 
safely as a cathartic in such doses. Ammouio-ferric alum, tincture of 
chloride of iron, tannic and gallic acids, &c, are used as styptic medi- 
cines in some cases. Sponging the body with alum and brandy, or 
whisky, and water, at such temperature as is not chilling and yet is 
sedative to the circulation, will be the best local measure. 

NEUROSES. 

Under this head, of affections involving the innervation of the skin, 
I class Prurigo, Anaesthesia, and Neuralgia cutis. 

Prurigo. — Often placed under papulce, because sometimes minute 
pimples occur with it,— -the essence of this disease really is, intense 
itching without eruption. It is commonly divided into prurigo mitts, 
formicans, and senilis. Pruritus is the technical name for itching as 
a symptom. 

The difference between the first two varieties is one of degree. In 
the mitts, obstinacy rather than severity exists. In p. formicans, 
suffering may be extreme, pervading the body. Heat of a fire or of a 
bed, rubbing of the clothes, etc., may cause an irritation which drives 
the patient to rub and tear the skin, yet without relief. Sleep may 
thus be prevented, and the bodily as well as mental exhaustion so pro- 
duced may be great. The complaint is occasionally intermittent. 
Yery often it is confined to one or two portions of the body ; as the 
scrotum, vulva, anus (pruritus scroti, vulvce, avi, vel podicis), etc. 
Pruritus ant is often caused by worms ; especially ascarides. 

Prurigo senilis is so named because of its frequency in old people. 
Lice cause it not unfrequently. Papulae attend it more often than 
the other forms. 

Treatment. — This is sometimes a very hard disease to cure, or 
even relieve. We must consider and treat the general condition of 
the body ; see that the bowels are regular, the digestion normal, the 
30 



350 SKIN DISEASES. 

skin kept clean and open by ablutions and proper change of clothing. 
Sometimes nervine tonics may be required ; as nux vomica, arsenic, 
or quinine, in small doses. Tincture of aconite is prescribed by some ; 
three or four drops at a time twice or thrice daily. Oonium, bella- 
donna, and other narcotics have been advised. The hypodermic in- 
jection of morphia may be resorted to to give rest in very distressing 
cases. 

Locally, many things may, and should, be tried in succession, in the 
search for palliatives. Baths of flaxseed tea, with or without carbon- 
ate of soda or of potassa ; lathering with castile soap, with a shaving 
brush ; strong salt water, or whisky and salt ; dilute sulphuric, nitric, 
or acetic acid [F. 190, 191, 192, 193] ; mercurial ointment; ointment 
of creasote [F. 224] ; cerate of white lead ; laudanum, sp. camphor, 
aconite, or chloroform, as lotion or in liniment; spirituous solution of 
corrosive sublimate [F. 194] ; solution (dilute) of hydrocyanic acid 
[F. 195] ; glyceramyl ; pure glycerin; tar ointment; olive oil ; tobacco 
infusion ; the " Turkish," or hot air bath ; and the common hot water 
bath ; these are only a few of the measures which may be resorted to. 
The diet should be unstimulating. Advice should be given to the 
patient also to refrain as much as possible from violence in rubbing 
or scratching the parts affected ; and not to sleep in a very warm 
room or under too much cover. 

Anaesthesia cutis is only a symptom of a larger affection — involv- 
ing either the nervous system or the skin itself. It appears in one 
variety of elephantiasis GraBcorum, called by some lepra dncesthetica. 
Yitiligo also is often attended by it, at the parts which undergo dis- 
coloration. Except stimulating frictions, when not contra-indicated 
by the other conditions of the case, and galvanism (faradization), 
under the same limitations, we have no special remedies to mention 
for loss of sensibility in the skin. 

Neuralgia of the skin, temporarily, at least, limited to it, does 
undoubtedly occur, though seldom. I have experienced it in my own 
person. Its locality does not, however, so remove it from other forms 
of neuralgia as to require for it a special consideration. 

PARASITICUS. 

Dermatologists are not all agreed upon the question, whether the 
microphytes or epiphytes (minute parasitic vegetations) discovered by 
aid of the microscope, in connection with certain skin diseases, are 
essential to these diseases, or accidental and secondary only. Wilson 
even denies their vegetative nature; asserting them to be results of 
spontaneous granular degeneration of epithelium. Most authorities 
hold the opinion, which I fully believe to be correct (especially 
proved by the results of treatment), that the parasites are really the 
essential causes of the disorders they constantly attend ; that they 
may, under favorable circumstances, be transplanted; and that, to 
cure those disorders, destruction of the parasitic forms is necessary. 
Again, Hebra, a high European authority, believes that all the epi- 
phytes described are merely modifications of one and the same species, 
in different degrees of development. Tilbury Fox agrees with this 



PARASITICA. 351 

opinion. B. Hallier 1 makes three series (Mucor, Achorion, Lepto- 
thryx) of forms, all capable of being educed from the same spores 
under different circumstances. Devergie believes in spontaneous 
generation of the epiphytes, although truly vegetable. Dr. MeCall 
Anderson 2 gives proofs, by separate inoculation, of the non-identity 
of three vegetative parasites at least — trichophyton, achorion, and 
microsporon. 

No doubt exists with the large majority of observers as to the cause 
of the animal parasitic eruption, scabies or itch. 

Scabies. — Chiefly vesicular, this disease may be papular, scaly, or 
pustular in some instances. Ordinarily we see, especially between 
the fingers and on the back of the hand, next often on the arms, legs, 
and abdomen, occasionally on the scalp, hardly ever on the face. — a 
number of small red elevations with white or watery tops. Extreme 
itching is always present ; often keeping the individual scratching night 
and day. King James I. is said to have described his experience of 
it as rather pleasurable ; but this is not the common account of it. 

Closely looking at almost any of the vesicles, one may see a little 
red line or track, at the end of which may be found a slightly elevated 
point. In this is. generally, the animalcule — Sarcoptes hominis 
(Acarus scabiei) ; one of the Arachnida. — flat bellied, round backed, 
tortoise-shaped, eight-legged ; the female larger than the male, which 
is hard to find. 

Treatment. — Sulphur is. not the only, but the most reliable and 
convenient parasiticide for itch. After thorough bathing, and wash- 
ing of the whole body with soap and water, strong sulphur ointment 
must be rubbed well into the parts affected. A few applications will 
usually suffice [F. 197]. The animalcule is killed, and the cure 
follows. There is evidence, however, that in some cases of long 
standing, recovery may follow but very slowly. The habit of the 
eruption has then become established in the skin : this must be treated 
like eczema, or lichen, whichever it most resembles. 

Oil of turpentine, kerosene or petroleum, ointment of sulphuric 
acid, and other powerful agents, may be also confidently relied upon 
to destroy the itch animalcule. 

Army-Itch. — During and since the late war in this country, the 
inevitable filth of camp-life begot, among other evils, a very trouble- 
some contagious skin-disease, called by the above name. Itching, 
without any eruption except small papuke. characterizes it. Outside 
of the army it has extended to a considerable number of persons. 
Xo better remedy for this affection, I believe, has been found than a 
lotion and ointment, composed of iodide of potassium and glycerin ; 
with water or rose-water for the lotion, and lard or cold cream for the 
ointment [F. 192, 199]. Mercurial ointment, and sulphuric acid 
ointment, are also efficacious for it. 

The other parasitic affections of the skin depend upon the micro- 
phytes already alluded to. They are Favus, Sycosis, Tinea Circina- 
tus. Tinea Decalvans. Chloasma versicolor, and Plica Polonica. 

Favus. — (Porrigo, Tinea favosa.) Generally appearing on the 

1 Archiv fur Mikroscopische Anatomie, April, 1866. 

2 Brit, and For. Medico-Chirurg. Rev., July, 1866, p. 225. 



352 SKIN DISEASES. 

scalp, this disease is peculiar in the formation of yellow cnp-shaped 
crusts, in each of which one or two hairs grow. By joining together, 
these crusts may lose their regularity of shape, in a general scabbing ; 
and a good deal of hair may fall out. A mealy powder is found in 
the crusts, which, on microscopic examination, is found to contain the 
formation called achorion Schonleinii by Remak. This presents 
minute tortuous branching tubes, straight or crooked not branching 
tubes, and sporules, free or united in bead-like strings. Granules and 
cellules of mycelium, the generative portion of the plant, are abun- 
dant. An offensive discharge occurs from the eruption in bad cases. 

Favus is contagious, though seldom conveyed to cleanly persons. 
It is hard to cure, but not incurable. In its treatment, constitutional 
and local measures must be combined. Arsenic is as usual the most 
reliable alterative. Neligan has advised the iodide of arsenic, gr. T ^ 
thrice daily ; intermitted if headache or dryness of the mouth come on. 

For the local treatment, the hair must be closely cut with sharp 
scissors. Apply then a large flaxseed poultice for twelve hours or 
more, — perhaps repeatedly, to soften the crusts. Next, wash the 
head thoroughly, by means of a soft sponge, with solution of carbonate 
of potassa (one drachm to a pint of water) ; after which ointment of 
carbonate of potassa (potass, carb. gj, glycerin fgj, adipis gj) may be 
applied spread thickly on lint, covered with oiled silk. This may be 
renewed daily; or, if there be much discharge, twice a day. The 
crusts will then come away in a few days. Ointment of iodide of lead 
may follow ; washing the head night and morning, still with the car- 
bonate of potassa lotion ; and keeping the hair cropped short all the 
time. Three or four weeks will generally suffice for a cure. Cleanli 
ness of person and regulated diet are at the same time, of course, 
essential. 

For this and other parasitic affections of the skin, tar ointment is 
a far from contemptible remedy. 

Sycosis (Mentagra). — This occurs on the bearded part of the face, 
chiefly the chin. It is contagious ; sometimes being transmitted by 
uncleanly barbers in shaving. It presents slightly inflamed elevations 
about the roots of the hairs, covered by scurf; shaving decapitates 
these, inducing irritation and suppuration, as well as scabbing. The 
whole chin may become swollen and inflamed by it ; and parts of the 
beard may be destroyed. The parasitic cause of this disease is the 
trichophyton mentagrophytes (microsporon mentagrophytes of Gruby). 
It is seen under the microscope to consist of minute stems, bifurcated 
at angles of from 40° to 80°, and granulated within. 

Sycosis is not common. Acne, impetigo, and ecthyma of the bearded 
part of the face may be confounded with it. It is very hard to cure. 
In its treatment, keeping the beard constantly very short by close 
clipping (not shaving) is essential. Sponging twice daily with castile 
soap and water, or carbonate of potassa lotion, will be beneficial. 
Iodide of lead ointment, ointment of nitrate of mercury, and of calomel 
and camphor, &c, may be used in succession ; besides the internal 
use of arsenic. 

Tinea Circinatus {Ring-worm. Scald-head).— This is known by its 
circular form, occurring most often, though far from always, on the 
head or face. Herpes circinatus resembles it ; but in that minute 



SYPHILTDA. 353 

vesicles are unusual ; in tinea, rare and few. Tn tinea a thin powdery 
crust exists, whose examination will show the trichophyton tonsurans, 
closely allied to the parasite of sycosis. 

Tinea decalvans is marked by a destruction of the hair in circular 
patches, making round spots of baldness. Its parasite is considered 
by many dermatologists as different from the trichophyton, and called 
microsporon Audouinii. Its sporules are rounder and smaller than 
those of trichophyton. 

The treatment of both forms of tinea must be, besides cleansing, 
essentially parasiticide. Tar ointment ; " huile de cade;" mercurial 
ointment ; solution of corrosive sublimate ; lotion and ointment of 
carbonate of potassa ; lotion of sulphurous acid ; carbolic acid ; 
creasote ; cantharidal collodion, lightly applied ; these are among the 
many applications which maybe used for the purpose, with generally 
successful result. 

As has been observed, tinea is seldom transmitted to a cleanly 
person ; at least without very close and continued contact. 

Chloasma Versicolor {Pityriasis Versicolor). — The parasite of 
this is microsporon furfur. The disease is recognized by the forma- 
tion of dull, reddish-yellow spots of various size and shape, seldom 
numerous, on the front of the chest or abdomen. The same local 
applications may be used for it as for tinea ; besides the internal use 
of arsenic. 

Plica Polonica. — This is an affection of the hairy scalp, endemic 
in Poland, Russia, and Tartary. The hair-follicles become diseased, 
and the hair is matted and glued together into felt-like masses. Tri- 
chophyton tonsurans and trichophyton sporuloides are the parasitic 
vegetations described as found connected with it. The disease has 
not been seen in this country. 

SYPHILILA. 

Enough for our purpose and space has already been said of the 
general history of syphilis. Among its constitutional manifestations, 
cutaneous eruptions are very frequent. These are seldom vesicular, 
not very often papular ; most often squamous or scabbing. Lepra 
and rupia, particularly the latter, are prominent among syphilitic 
affections, though both may occur independently of syphilis. All 
eruptions in persons of this diathesis are marked by a coppery color, 
which remains long, even after their cure ; by a disposition to ulcerate, 
perhaps only superficially ; and by preference in locality for the face, 
shoulder, and back. 

In the treatment of syphilitic eruptions, the diathesis must be met 
by our remedies. Iodide of mercury internally ; after that, iodide of 
potassium, and, in feeble persons, cod-liver oil, perhaps iodide of iron ; 
locally, mercurial ointment (besides palliatives, if required, as in other 
eruptions), or the calomel vapor bath, should be prescribed. Often, 
such affections will seem to be cured, but, after weeks or months, will 
return again ; then the treatment should be renewed, and discontinued 
when they disappear. 

30* 



354 SKIN DISEASES. 



POISON- VINE ERUPTION. 

The common poison-vine (Bhus toxicodendron), 1 a species of sumach, , 
and one or two other plants more rarely, cause, by contact, in some 
persons, an inflamed vesicular eruption of considerable severity. 
The hands and face are its most common localities ; but it may come 
out on the lower limbs or about the anus and genitals. Its duration, 
when severe, may be from one to two weeks ; but it is often quite 
limited and of shorter course. 

In the treatment of this annoying but not dangerous attack I have 
had a good deal of experience in my own person as well as with 
others. I have found the most relief, and the greatest effect in short- 
ening the course of the disease, by reducing the inflammation, from 
lead-water, early, freely and frequently applied, with a large camel's 
hair pencil. It should not be put upon the opened vesicles, which it 
irritates ; but around them, upon the reddened skin. In the practice 
of my brother, Dr. E. Hartshorne, a very successful remedy has re- 
cently been the fluid extract of serpent aria, painted directly upon the 
eruption. It seems to kill it at once. 

FROST-BITE ; CHILBLAIN. 

Gangrenous destruction of parts, especially of toes, not unfrequently 
follows actual congelation. Short of this, exposure to continued cold, 
especially when suddenly warmed again, may cause an erythematous 
inflammation, erythema pernio, already mentioned under that head. 
When the feet or other parts have been so chilled as to be almost 
frozen, gradual warming — for instance, at first, rubbing them with 
snow — is proper, as a preventive of frosting. In its treatment (as 
remarked before), cooling unguents, as Goulard's cerate, or lotions, as 
lead-water, may be first wanted, and then astringents, as alum water, 
infusion of oak bark, creasote ointment, &c. Cabbage-leaves are a 
popular domestic remedy for chilblains. 

BURNS AND SCALDS. 

If half of the body be so burned or scalded as to arrest the func- 
tions of the skin over that much of the surface, death will always re- 
sult. Collapse comes on, from the terrible shock to the nervous 
system through the impression on the widely distributed cutaneous 
nerves. The pulse is then very low, the body cold, and, commonly, 
thirst is great. Even suffering is often, in a few hours, lost in apathy 
and prostration. 

The treatment for this condition must be stimulant as well as ano- 
dyne. Brandy or whisky or wine should be given, as freely as in any 
other condition of positive debility or exhaustion. 

For local treatment of burns, I believe nothing is better than lime- 
water and oil, equal parts (either linseed, olive, or lard oil) on cotton 
wadding, covered with oiled silk. Other remedies often used are dry 
cotton (which sticks too close in deep burns), glycerin, rye-meal, starch 

1 This resembles the Virginia Creeper, but is unlike it in being three-leafed. 



AMENORRHCEA. 355 

powder, and molasses. To exclude the air seems to be the cardinal 
object. 

UNCLASSIFIED AFFECTIONS. 

AMENORRHEA. 

A few words seem appropriate here upon some of those affections 
of the sexual system which every practitioner must often meet with. 
Their full discussion belongs to books of a different kind. 

Amenorrhcea, or suppression of the menstrual discharge in 
women, may be either an interruption of it, during its occurrence, 
or its habitual non-appearance. The former is commonly the result 
of cold and wet, or some nervous shock, to which the patient is exposed 
during the menstrual period. 

Habitual amenorrhcea may occur with plethora, from disturbance 
of ovarian and uterine functions; or with anaemia and debility; or, 
as a secondary effect of chronic disease, e. g. phthisis. The greater 
number of cases is in anaemic females; but the opposite state is not 
uncommon. Vicarious hemorrhages, from the lungs, stomach, &c, 
sometimes accompany it. 

As bearing upon the treatment of amenorrhcea. the question always 
comes up — is the suppression of the menstrual flow the cause of other 
symptoms or morbid effects, or. is the amenorrhcea itself the effect of 
a morbid condition, the removal of which will restore this arrested 
function ? It is to be said in reply, that sometimes the one, and some- 
times the other may be the case. In anaemia with plethora, generally 
the interruption of menstruation may be found to be a primary, though 
perhaps not the sole, cause of disturbance of the system. In anaemic 
amenorrhcea, most frequently the constitutional state is primary ; and 
the restoration of general strength will be attended by the spontane- 
ous return of the function. 

Practically, then, we must, in any case, inquire into the general 
condition and history of the patient. If there is headache, increased 
by stooping, with a flushed face, and full, strong pulse, the patient 
having previously been vigorous in health, taking blood from the 
lumbar region by cups, or, in clear cases, from a vein in the arm by 
the lancet, is indicated. Also, purgatives ; at first, in a sudden attack, 
senna, or, if much heat of the system exist, citrate or sulphate of 
magnesia ; afterwards, when the amenorrhcea is obstinate, aloes. Hot 
mustard foot-baths, or warm hip-baths, and warm poultices to the 
breasts, every night, should be used in a case of sudden suppression 
of menstruation in the midst of its time. Tincture of aloes and myrrh 
is a favorite domestic emmenagogue ; a teaspoonful twice or thrice 
daily, in hot water. Black hellebore, savin, seneka, &c, are also 
resorted to for similar action ; but all emmenagogues are more uncer- 
tain, even, than diuretics. 

In many cases of amenorrhcea, a delicate, and in some a difficult 
question, is, as to the possibility of the (physiologically) normal cause 
of pregnancy being present to account for it. Most of all may this 
difficulty present, of course, in young single women ; who may. unfor- 
tunately, have reason for concealment. Apart from the very clear 



356 UNCLASSIFIED DISEASES. 

ethical principle, that a physician has no moral right to aid, in any- 
way whatever, in producing an abortion, active emmenagogue treat- 
ment in the pregnant state is unsafe for the health of the subject of it 
herself. Medicine will fail to cause abortion, in eight or nine cases in 
ten, unless it be so used as to produce a serious, often dangerous 
effect upon the system of the patient. 

When we suspect pregnancy, then, mild measures only are in place, 
- — waiting for time to develop the nature of the case in full. Ancemic 
amenorrhcea requires tonics ; above all, iron. Other medicinal and 
hygienic roborant agencies may also be called in. Aloes, in small 
doses, repeated daily [F. 201, 202], occasional or periodical hip-baths, 
foot-baths, and breast-poultices, especially near the time when the 
menstrual flow should occur, — may in many cases be super-added. 
Strychnia, in one-thirtieth of a grain doses, is a favorite tonic in 
amenorrhcea with some practitioners. Galvanism, or statical electri- 
city (of the friction-machine) is much resorted to by others. The 
spinal and pelvic regions are the seats of the application. 

DYSMENORRHEA. 

Painful menstruation is habitual with some women for years toge- 
ther. Pregnancy not unfrequently cures the habit. The affection 
seems to be of two kinds or origins ; 1. functional or physiological, 
and 2. mechanical dysmenorrhcea. With the former, disorder of 
innervation and circulation occurs ; even the ovaries may partake in 
this. I attended one woman in a number of attacks of monthly ovarian 
irritation (ovarian colic) of extreme violence and suffering, with fever. 
Ordinarily, before menstruation begins, the subject of functional dys- 
menorrhcea feels ill, with pain in the back, perhaps headache ; followed 
by pains almost like labor-pains, of the first stage, in the womb. That 
organ becomes palpably swollen and heavy, its pain being somewhat 
assuaged by compression by the hand through the abdominal wall. 
When free discharge comes on, relief is obtained. 

The symptoms of mechanical dysmenorrhcea are not always 
strikingly different, but it is a more local affection. The direct cause 
of it is obstruction at the os or cervix uteri ; the external or internal 
os usually, if constriction be the trouble; in the neck, when anteversion, 
retroversion, or lateral flexion produces it. On the indication of this 
causation, Dr. Simpson of Edinburgh some years since introduced 
the practice of dilatation of the os and cervix, for the cure not only 
of dysmenorrhcea, but of sterility also, dependent upon the same 
obstruction. A sponge-tent was used [F. 232] ; sometimes, more lately, 
the sea-tangle (laminaria digitata) instead. Simpson and others, how- 
ever, still more recently, prefer incising the neck of the uterus, with 
a hysterotome ; asserting that this is more certain, and even less 
dangerous. Much discussion on this subject has transpired in late 
journals. I must refer upon it to works on special surgery ; particularly 
the last work of Dr. Marion Sims. It is observable, however, that 
Dr. H. R. Storer, the distinguished obstetrician of Boston, adheres to 
careful dilatation, instead of incision. Drs. Tilt and H. Bennet of 
London also object to frequent hysterotomy. 

Whatever the cause of dysmenorrhcea in any case, the subject of it 



MENORRHAGIA — LEUCORR HCE A. 357 

should always avoid being much on her feet for a day or two before 
her monthly time : and should go to bed when the pain begins. Cloths 
wrung out of hot water, or spirits and water, may be placed upon the 
abdomen, and renewed as they cool. Internally, spirits of camphor, 
with compound spirits of lavender and hot water (sweetened to taste) 
may be given [F. 203] : or. if not relieved, paregoric, in teaspoonful 
doses. The advantage of avoiding much exercise or fatigue just 
before the time of the expected menses, ought to be impressed upon the 
patient. No medicine appears to have any important prophylactic 
effect. 

MENORRHAGIA. 

Excessive menstruation may be of two kinds : 1. its occurrence too 
often ; 2. too great an amount or continuance of the discharge. Both 
very often occur together. Causes of monorrhagia are. — general 
relaxation of system : over-excitement of the genital apparatus : thin- 
ness of the blood, hemorrhagic diathesis : and over-fatigue, especially 
on the feet, promoting a descent of blood toward the pelvic organs 
about the time of menstruation. Ulceration, cancer, or tumors of the 
uterus, as well as abortion and placenta prcevia. cause uterine hemor- 
rhage, not properly to be called monorrhagia. 

This affection is much most common in the ansemic. Rest, iron, 
good diet, and astringents, internally and sometimes locally, are the 
remedies for it. Tincture of chloride of iron is, here, the favorite chaly- 
beate. It may be given through the interval. During the attack, 
ammonio-ferric alum, in five grain doses, may be administered : or 
tannic or gallic acid, three to five grains several times daily. The 
patient must be kept still upon her back till the flow is controlled. 
Sometimes cold wet cloths (for a serious hemorrhage) have to be put 
upon the abdomen ; or an ice-water sponge, or half a lemon, or a 
syringeful of tannin and solution, or of solution of tinct. ferri chlorid. 
(f^ss in f^viij) may be thrown into the vagina. Plugging, with a 
tampon of cotton, lint, or sponge. 1 in a few instances may have to 
be resorted to. In every case of severe or protracted monorrhagia. 
the practitioner must endeavor to be sure whether or not any malig- 
nant or other organic affection of the uterus is present. 

LETJCORRHCEA. 

Synonyms. Fluor Albus ; the Whites. — This is a quite common 
trouble of women. The mucous discharge may be either from the 
vagina or from the uterine cavity. Irritation of the organs, followed 
by relaxation, is its general cause ; but. often, relaxation alone seems 
capable of producing it. Procidentia or prolapsus uteri is a frequent 
source of it: the descended uterus pressing upon the vaginal walls, 
causing morbid increase of secretion and exhalation from one or both. 

In treatment of leucorrhcea. tonics are often required : iron, bitters, 
<£c. Also, astringents, by the mouth and locally; those mentioned 

1 Dr. T. E. Beesley has contrived a light metallic conical plug or cork for 
the vagina ; to be kept in place by a bandage. 



358 UNCLASSIFIED DISEASES. 

for menorrhagia will apply here also, but usually in less strength, for 
a longer time [F. 204, 205]. If prolapsus or procidentia exist, I 
believe that a well-adapted pessary (gutta percha or India rubber 
ring, or double horseshoe of similar light material) will in a majority 
of cases do good service. 

SPERMATORRHEA. 

Referring the reader for a full consideration of this subject to 
Bartholow,' Acton, or other authorities, the main facts only will be 
here stated. In continent men of full health, an involuntary seminal 
discharge during sleep once in two or three weeks is common ; and is 
then so innocent as to be regarded by many as physiological or normal. 
More frequent emissions are abnormal, in proportion to their frequency; 
and may cause much loss of strength. While haemorrhoids, worms in 
the bowels, &c, may occasionally promote this, the cause of actually 
excessive spermatorrhoea in ninety-nine cases (at least) in a hundred 
must be believed to be self-abuse. The cure of this habit is, not 
always at once, but almost certainly in the end, the cure of the result- 
ing spermatorrhoea. The disastrous effects so obvious in many cases 
are due first to the vicious habit, and, secondarily only, to the involun- 
tary discharges. 

In pathology, Lallemand has, for a long time, been allowed to im- 
pose upon the medical mind his opinion that irritation or inflammation 
of the prostatic portion of the urethra is the general or universal 
immediate cause of spermatorrhoea. As Bartholow more correctly 
states, this is quite exceptional. More largely by far, spermatorrhoea 
shows itself to be a cerebro-spinal neurosis. That is, the error is not 
in the local structure of the urethra, but in the morbid nervous 
excitability ; which renews too often the sexual orgasm, somewhat 
after the manner of an eclampsia or convulsion, as a reflex act. 

It is to be remembered that, in a relaxed state of the system, espe- 
cially in those whose genital organs have been more or less abused, in 
natural or unnatural ways, sometimes a mucous discharge of small 
amount may occur from the urethra, like the leucorrhoea of the female. 
Only the presence of spermatozoa, visible with the microscope, proves 
seminal loss. 

What are we to do, then, when consulted by a patient for sperma- 
torrhoea? Ascertain the frequency of the discharges, the state of his 
general health, and, if possible, his habits. Relieve unwarranted 
alarm by stating the innocence of bi-weekly spontaneous evacuation 
of the seminal ducts ; whose effect is quite different from that of the un- 
natural violence and mechanical irritation of self-indulgence. Impress 
upon him, whether the habit be acknowledged or not, that his danger 
lies in it, and that his cure depends upon entire and permanent absti- 
nence. 

To promote this, all moral impressions must be brought to bear 
upon his mind, as well as prudential considerations. Active muscular 
exercise in the open air (in proportion to strength) should be encour- 

1 On Spermatorrhoea, &c. By Roberts Bartholow, A. M., M. D., &c. New 
York, 1866. 



SPERMATORRHEA. 359 

aged, even to fatigue. He should eat very light suppers, sleep under 
light clothes, rise early, and bathe often in cool or cold water. The 
shower-bath will do very well. Iron is required in really weak cases, 
as a tonic. The diet should be nourishing, but not stimulant ; avoiding 
high seasoning, and alcoholic beverages. 

Of all drugs said to be anaphrodisiac (i. e., capable of diminishing 
or quelling sexual appetite) I believe that none have any available 
power except lupulin and bromide of potassium. The dose of the 
former for this purpose is ten grains, at bedtime. Bromide of potas- 
sium is, however, the medicine of the day for reducing excitability of 
organs subject to reflex action. Twenty grains at bedtime, every 
night, will, according to my observation in practice, make a great 
difference with those who are troubled with frequent nocturnal dis- 
charges. 

Lallemand's porte-caustique finds justification only upon his theory 
of urethral or prostatic disease as the cause of spermatorrhoea. 
Without feeling warranted in denying the occasional existence of such 
a lesion, and the possible benefit of limited cauterization in such an 
exceptional case, I am not prepared to believe in its frequency or 
great importance. 

Acton. 1 however, has confidence in cauterization in a number of 
cases. He employs a solution of nitrate of silver, ten grains to the 
ounce of water ; which he injects into the urethra by means of an 
instrument consisting of a glass syringe attached to a tube like a short 
catheter. The part to be acted upon is the irritable membranous 
portion of the urethra. Before using the caustic the patient should 
empty the bladder. The pain of the application is considerable. 
After the operation, Acton advises a copaiba capsule every eight 
hours, for two or three days ; also, that the patient drink as little 
water as possible, and avoid passing urine as long as he can. After 
once urinating, he is allowed to drink watery fluids as usual. The 
scalding and oozing of blood gradually disappear. 

Mechanical means are sometimes employed to prevent nocturnal 
emissions; e.g., a light metallic ring to surround the penis, having 
teeth projecting inwards ; so that erection awakes the patient. In bad 
cases, where epilepsy, insanity, or extreme general exhaustion has fol- 
lowed a seemingly incurable habit of self-abuse, circumcision would 
really seem to be justifiable ; more so, surely, than the more serious 
and dangerous operation of castration. Baker Brown's analogous 
operation to remove " peripheral irritation" as a cause of grave ner- 
vous maladies in the other sex, by excision of the clitoris, has met, 
recently, with decided opposition from no* less an authority than Dr. 
Charles West, of London, as well as from others. 

As signs of waste of substance and vigor by seminal losses, we find 
mentioned, pallor, with dark lines under the eyes, inability to look any 
one in the face, cold, moist hands, frequent flushing of the countenance, 
aversion to society. But these symptoms of general and nervous 
debility may all exist without being thus accounted for. 

1 On the Reproductive Organs, Phil, ed-, p. 243. 



3G0 UNCLASSIFIED DISEASES. 



WORMS— ENTOZOA. 

Helmillthology, the study of worms, has assumed of late a very 
considerable importance in connection with medicine. About thirty 
entozoa inhabit different parts of the body of man. They have been 
generally classified as Coelelmintha or hollow worms, and titerelmintha 
or solid worms, i. e., without any well-defined alimentary cavity. Broad 
or flat worms, Platelmm, and thread-like or cord-shaped worms, iVe- 
matelmia, constitute another arrangement. Of the flat worms, some 
are Cestoid, or riband-like ; others Trematode, or fluke-like. The most 
important ones are enumerated in the following table : — 

Cestoid Worms : 

Mature : Taenia solium ; Taenia echinococcus ; 

Taenia mediocanellata ; Bothriocephalic latus ; 

Immature : Cysticercus cellulosae ; Cysticercus t. mediocanellatae. 
Echinococcus hominis. 

Trematode Worms : 

Distoma hepaticum (fasciola hepatica). Bilharzia haematobia; 
Distoma ophthalmobium. Tetrastoma renale. 

Nematoid Worms : 

Ascaris lumbricoides ; Sclerostoma duodenale ; 

Trichocephalus dispar ; Filaria medinensis ; 

Oxyuris (ascaris) vermicularis ; Strongylus gigas. 
Trichina spiralis. 
Most curious are the transformations some of these parasites un- 
dergo. Pallas, 1776, stated that all cystic worms were forms of a 
tape-worm. Steenstrup, in 1842, discovered the " alternation of gene- 
rations" in some small aquatic worms, cercarice. Kuchenmeister and 
Siebold proved by actual experiment that hydatid parasites are young 
or immature tape-worms. Humbert, of Geneva, in 1854, swallowed 
fourteen cysticerci, and in three months discharged fragments oftceniw, 
which had developed within his body. The immature forms are non- 
sexual ; they may remain, as in hydatids, for a long time, in solid 
organs, without development. They only become mature and sexual, 
capable of reproduction, in parts of the body having some communi- 
cation with the external air, as in the alimentary canal or lungs ; 
generally the former. Migration from one part of the body to another 
occurs with some ; as trichina spiralis. 

Taenia solium and taenia mediocanellata look a good deal alike ; 
but the former is much the smaller. The immature cysticercus of the 
former is j 9 ^ of an inch long : that of the latter, of the size of a pea. 
The t. solium has a circle of hooklets around a convexity of the head ; 
the mediocanellata is club-headed, with larger sucking disks than the 
solium has. One is designated as " armed" and the other " unarmed" 
tape-worm. The former is from the cysticercus cellulose of the hog ; 
the latter from the " cysticercus bovis" 1 (Cobbold) ; and is the most 
common. The unarmed is the easiest to drive out. 

1 Cobbold states that the hydatid of the cysticercus bovis has never yet been 
observed in man. Hydatid or "echinococcus" disease is especially frequent 
in Iceland. 



TREMATODE WORMS. 361 

The tape-worm is formed of flat segments, often several hundred in 
number, connected with the head by a slender neck. Each segment 
has male and female organs (hermaphrodite) ; as those at the tail ma- 
ture, they are cast off. Some patients thus pass six or eight fragments 
from the bowels in a day. The whole length of the parasite is from 
ten to thirty feet. 

The symptoms caused by tape-worm are not very determinate. 
They resemble those produced by other worms ; namely, uneasy sen- 
sations in the abdomen, and general nervous irritation ; bad sleep, 
attacks offaintness, and lowness of spirits, indigestion, irregularity of 
appetite and of the action of the bowels ; itching of the nose, and 
sometimes of the anus. Epilepsy and insanity are said to have some- 
times been caused by it. The only proof of tape-worm is the finding 
of fragments of it in the stools. It is a common impression that it is 
never destroyed unless the head is discoverable ; but this is not exactly 
true. Conversely, if the head comes away, the parasite to which it 
belongs is no longer reproduced. More than one of them may, how- 
ever, be present at once ; though this is rare. 

The broad tape-worm, bothriocephalic, is known only in northern 
central Europe; Russia, Sweden, Norway, Lapland. Finland. Poland, 
and Switzerland. Its head is elongated, compressed, obtuse ; its length 
from six to twenty or twenty five feet. It does not give off detached 
segments. Cobbold says it is indigenous to Ireland; although he has 
never met with a patient born in that country who has been the sub- 
ject of it. 

Treatment of Tape-worm. Oil of Turpentine, in half ounce or 
ounce doses, will generally purge, and bring away the worm. It in- 
toxicates some persons. In Egypt, petroleum is used for the same 
purpose, in doses of twenty or thirty drops. The ethereal extract 
(commonly called oil) of male fern, extractum filicis liquidum, U. S. 
Pharm., in the dose of a drachm and a half to two drachms, is esteemed 
highly by some practitioners. Konsso, the flower of the Brayera 
anthelmintica of Abyssinia, in half ounce doses, mixed with water, 
given on an empty stomach, is almost certain to destroy or remove the 
parasite. So is said to be Kameela, the Rattler a tinctoria of botan- 
ists. Pumpkin seeds, plentifully taken on an empty stomach, are 
quite effectual. 

Prevention of Tape-worm. — As immature tape-worms find resi- 
dence in the bodies of animals used for food, and thus get the op- 
portunity to enter the human alimentary canal, the avoidance of raiu 
or under-cooked meat is the precept of prophylaxis suggested, and 
confirmed by experience. This applies not only to the prevention of 
tape-worm, but, also, to that of other parasites, especially trichina?. 
Tape-worms are derivable from infested beef, even oftener (Cobbold) 
than from pork. Mutton has been found occasionally to contain cys- 
ticerci. 

TREMATODE WORMS. 

These are the Distomata, Bilharzia hcemotobia, Tetrastoma renale, 
and others. They are of a flattened oval shape, soft and smooth. 
Thev have a bifurcating alimentary canal, with a mouth, but no anus. 
31 



362 UNCLASSIFIED DISEASES. 

Both sexes are upon one individual. They exist in two conditions, 
mature and encysted, and immature and free. Their methods of repro- 
duction are very curious, but of greater importance in zoological than 
in pathological science. 

Distoma hepaticum, found sometimes in the liver and its ducts, 
measures about an inch in length when mature, and rather less than 
half an inch in width. 

Distoma ophthalmobium has been found in the eye of a child 
having congenital cataract. It is about half a line (^ ¥ in.) in length. 

Bilharzia haematobia is found in great abundance in Egypt; 
where it inhabits the veins of the abdominal organs of the inhabit- 
ants, in the proportion of nearly one-third of the population. Hemor- 
rhage from the kidney, and the symptoms of dysentery, may follow 
from its presence. It is not more than three or four lines (\ to J in.) 
in length. The sexes are on different individuals. 

Tetrastoma renale is occasionally found in the substance of the 
kidney. It is nearly half an inch long. 

NEMATOID, OR ROUND WORMS. 

Ascaris lumbricoides is the commonest of entozoa. It inhabits 
mostly the small intestines ; bat may get into the stomach, and, of 
course, the large intestines. I have repeatedly known them to be 
vomited from the stomach. This round worm is from five to fifteen 
inches in length, light-brown in color, tapering to a point at each end. 
A considerable number of them may exist together ; it is only then 
that their presence in the bowels is likely to do much harm, unless in 
very susceptible children. Their escape into the stomach may cause 
nausea, vomiting, and indigestion, sometimes difficult to account for 
until the throwing up of the worm explains the cause. I have known 
this to happen in an adult, in whom the symptoms of gastric irrita- 
tion continued for two or three weeks. These worms probably enter 
the body chiefly in the drinking water of shallow wells, muddy 
streams, etc. 

Treatment ; Diagnosis. — Two things are wanted : to expel the 
worms present, and to prevent their re-accumulation. As to the 
evidence of the existence of lumbricoid worms in the bowels, it is 
always doubtful unless some of them pass out with the evacuations. 
Signs of gastro-intestinal and nervous irritation attend them, espe- 
cially in infants and young children. So, grinding the teeth during 
sleep, itching of the nose and anus, bad or irregular appetite, and 
tumidity of the abdomen, are regarded commonly as signs of worms. 
But other sources of indigestion and disturbance may be thus made 
known. Convulsions may undoubtedly be caused by worms in chil- 
dren; and so may laryngismus stridulus, and spasmodic croup. 

When there is good reason to believe that they do exist in the 
bowels, anthelmintics may be given, with purgatives, in safe doses, 
watching their effects. Besides the vermicides mentioned in connec- 
tion with tape-worm, many other drugs have more or less such effect; 
as santonin (most certain of all), calomel, pink-root (spigelia), bark of 
pomegranate root, azedarach, chenopodium, cowhage (mucuna), 
powder of tin, etc. [F. 206, 207, 208]. 



NEMATOID, OR ROUND WORMS. 363 

Infusion of senna and spigelia, half an ounce of each to a pint ; 
for an adult, a winglassful every morning before breakfast ; this is very 
popular in this country. Instead, may be given fluid extract of 
spigelia and senna, a teaspoonful for a dose. As above said, santonin 
is the most effectual of the vermicides or vermifuges. It requires 
care in its use, however; producing serious vomiting, prostration, and 
nervous symptoms in over-dose. A child should not take more than 
half a grain of santonin once or twice daily ; an adult, from three to 
six grains. 

Trichocephalus dispar. — This worm inhabits the large intestine. 
It has a length of an inch and a half to two inches. The head is 
attenuated or hair-like ; whence its name. The sexes are on different 
individuals. The trichocephalus is much less common than the lumbri- 
coid worm. 

Oxyuris vermiCTllaris {Ascaris vermicularis) — White seat-worm. 
Of this the male is about a line (yV inch) and a half long; the female, 
five or six lines. It is found in the rectum, generally of children ; 
sometimes in considerable numbers. They cause a great deal of 
itching ; occasionally, other nervous irritation. Females may have 
them find their way into the vagina ; more rarely, they get into the 
urethra. 

For the treatment of seat- worms, I know of nothing equal to sup- 
positories of santonin; made with cacao butter, three grains of the 
drug in each ; one to be introduced into the rectum every night [F. 
209]. Other common remedies are, injections of lime-water, infusion 
of aloes, mercurial ointment, etc. 

Trichina spiralis. — Since 1822, when Tiedeman discovered it (Hil- 
ton, 1832), and especially since it was described by Owen in 1835, the 
dissecting room has furnished observers with specimens of this para- 
site, long supposed to be harmless. Zenker of Dresden first showed 
that, although a few trichina? may be innocent, they sometimes abound 
to such an extent as to cause serious disease, and even to destroy life. 
Such an affection is called trichinous disease, trichiniasis or trichi- 
nosis. It has occurred particularly often in Germany, where it has 
been recognized since 1860. In 1863, in a Prussian town, of 103 
persons in good health who dined together on a festive occasion, 
nearly all became ill from eating sausage made of the meat of an ill- 
conditioned pig; and quite a number died. Another outbreak, at 
Hedersleben, in 1865, caused 40 deaths in 300 cases. The first cases 
in America were reported by Dr. Schnetter of New York. 1 At 
Marion, Iowa, in 1866, nine cases occurred in one family, under the 
care of Dr. J. H. Wilson ; five died. In the same county, eating raw 
ham containing trichinae (as proved afterwards by examination) caused 
the disease in six children at the same time ; reported by Dr. Ristine. 
An examination of pork in Chicago by a committee of the Academy 
of Sciences of that city proved the existence of trichina? in 1 in 50 of 
the hogs inspected; some of their muscles containing from 10,000 
to 18,000 in a cubic inch. Such animals are not themselves nearly 
always out of health. Cattle, also, are, to a less degree, subject to 
the same parasite. The meat of those so infected should of course 

1 Clymer, in Phil. ed. Aitken's Practice of Medicine, vol. i. p. 858. 



3f>4 UNCLASSIFIED DISEASES. 

not be used for food. In some German cities the butchers have 
microscopic examination made of the flesh of their animals. 

To the naked eye, the muscles of a trichinous animal present 
whitish dots, which a lens will show to be the capsules or cysts of 
immature trichinae. Those not encysted are invisible without a micro- 
scope. The capsule is hard and transparent; the worm is coiled 
spirally within it. Under the tongue is the preferred place to search 
for the trichinae in the living animal ; a delicate harpoon being used. 

The trichina is a minute bi-sexual worm, reproducing in the intes- 
tinal canal of animals or men ; the offspring then finding their way out 
through the walls of the intestines to become finally encysted in the 
muscles. The disease produced by them has two distinct stages: 1. 
that of the presence of the worms in the alimentary canal, and their 
multiplication there ; 2. that of their migration to and location in the 
muscles. Of the first period, malaise, vomiting, and diarrhoea are 
the leading symptoms. Of the second, fever, resembling typhoid, 
severe pains, with stiffness, in the muscles, and prostration. As the 
muscles of the larynx are often attacked, hoarseness is a common 
symptom. The complication of pneumonia is not infrequent. The 
first stage above mentioned lasts about a week or less ; the second 
may terminate fatally within six days, but usually has a duration of 
from two to four or five weeks. 

We are not informed of any success with the treatment of trichi- 
niasis. Its prevention is always possible. Besides proper inspection 
of animals, every piece of meat which may be suspected must be 
well cooked. Eeliance cannot be had upon salting and smoking; at 
least unless they be very thoroughly done. 

Sclerostoma duodenale is common in Egypt and in parts of 
Europe. It exists in the small intestines, and causes a chlorosis-like 
anaemia. The worm is from a third to half an inch long. Its vermi- 
cide is said to be turpentine. 

Strongylus gigas (Eustrongylus gigas) inhabits the kidney. It is 
rare in man. 

Filaria medinensis {Dracunculus) or Guinea-worm lives in the 
subcutaneous tissue. It is common in the tropical regions of the old 
world. The female worm it is, that enters the skin of a human being, 
and develops, with its contained young, in a whipcord-like shape, to a 
length varying from six inches to four, five, or six feet, and a width 
of about one twelfth of an inch. A dozen or more of the worms may 
exist upon the same person. The lower limbs are especially invaded 
by them ; but they can migrate almost all over the body. They evi- 
dently get into the legs and feet of those who bathe in shallow streams 
or ponds, or walk barefooted in damp and muddy places. An incuba- 
tion of a year or more is required for the development of the worm to 
a perceptible size. 

A characteristic vesicle appears, generally upon the lower part of 
the leg, when the worm matures. This bursts, emitting the young 
filariae ; a good deal of itching and irritation ensues, and sometimes 
ulceration.^ The natives often rid themselves of the worm by letting 
a s.tream of water run or pour for a time upon the leg. When it 
creeps partly out, they draw upon it until it is dislodged. 



EPIZOA — POISONS. 365 



EPIZOA. 



Parasitic animals living upon the surface of the body are (besides 
the sarcoptes), chiefly lice, fleas, and ticks. The former are the head 
louse (pediculus capitis), body louse (p. corporis), and crab louse (p. 
pubis). These are true insects, without wings. The preventive of 
them is cleanliness, with avoidance of contact with unclean persons. 
Their destruction must be accomplished either by assiduous search 
and slaughter, or by parasiticide lotions, ointments, or powders ; as, 
corrosive sublimate, cinnabar, pyrethrum, cocculus indicus, sulphur, 
carbolic acid, staphisagria, sabadilla, alcohol, essential oils [F. 210, 
211, 212]. 

Two or three grains of corrosive sublimate dissolved in an ounce 
of water with a drachm or so of alcohol, will be as effectual as any of 
these. Powder or ointment of cocculus indicus is a good deal used. 
The flea-powder of the East (quite useful in stupefying fleas in a bed, 
if sprinkled before lying down) is probably pyrethrum. 

Ticks belong with the arachnida of naturalists. People living in 
the country often have them to enter the skin from other animals or 
from plants ; e. g., the harvest-tick (leptus autumnalis). The irritation 
is moderate and local only. 

Fleas in most parts of the world produce only annoying bites, larger 
and somewhat more inflamed than mosquito-bites. In Brazil and 
other parts of South America, the chigoe or jigger (pulex penetrans), 
makes a more permanent lodgment, and causes a very considerable 
irritation. 

POISONS. 

A few memoranda upon the more common poisons may be con- 
venient here. Toxic agents are : 1. Irritant ; 2. Narcotic ; 3. Unclas- 
sified. 

Irritant or Corrosive Poisons.— 1. Acids; e.g., sulphuric, nitric, 
cldorohydric, oxalic. For all but the last, any alkaline substance 
(carbonate of soda, potassa, magnesia, or lime ; or magnesia or lime 
alone) dissolved in or mixed with water, will be suitable as an antidote. 
Oxalic acid should have lime-water freely used as its antidote. 2. 
Alkalies; e.g., caustic potassa, soda, strong solution of ammonia; 
earths, baryta, lime. For these vinegar or lemon-juice will act anti- 
dotally, making neutral salts. Olive or castor oil will saponify the 
alkaline material, and thus render it innocent. 

3. Corrosive Sublimate. — For this, whites of eggs, or wheat flour 
mixed with water will be the best. 4. Arsenic. — Hydrated peroxide 
of iron has the reputation of being an almost certain antidote for the 
common arsenical compound, arsenious acid or white oxide of arsenic. 
It may be made fresh by adding aqua ammoniac to liquor ferri per- 
sulphatis ; or aqua ammonice to tincture of the chloride of iron. It 
is well for every physician to have a pint of each of the two first- 
named articles always within reach. The precipitated hydrate should 
be given promptly and freely. Some toxicologists regard magnesia 
as an almost equally reliable antidote for arsenic. 5. Sulphate of 
Copper ; Salts of Tin. — Whites of eggs, milk, or flour mixed with 

31* 



366 UNCLASSIFIED DISEASES. 

water may be given freely, 6. Tartar Emetic. — Infusion of galls or 
oak bark, or tannic acid in solution, may be administered copiously. 
Afterwards, opiates, as paregoric, will help to compose the stomach 
and bowels. 7. Acetate of Lead. — Sulphate of magnesia is antidotal 
for this ; making the insoluble and inert sulphate of lead. 8. Sulphate 
of Iron (green vitriol) ; Sulphate of Zinc (white vitriol). — Carbonate 
of soda is recommended for these ; copiously diluted. Flaxseed tea 
is a good diluent for any corrosive poison. 9. Nitrate of Silver. — 
Common salt is its antidote ; making chloride of silver, inert. 10. 
Phosphorus. — A mustard emetic may be the first thing. In any 
poisoning, not accompanied by vomiting as an effect, this will be 
proper. Magnesia and mucilaginous infusions may then be given, 
quickly and largely. 11. Iodine.— Starch neutralizes iodine ; but it 
will not neutralize iodide of potassium ; for which no strict chemical 
antidote is known. 12. Creasote. — Whites of eggs, or milk, or flour 
and water, will combine with it. But, while waiting for these, free 
draughts of water should be given. 

Narcotic Poisons. — Opium. When this or any other such poison 
has been taken, if the patient can swallow, an emetic should be given ; 
ten grains of sulphate of copper, twenty grains of sulphate of zinc, half 
a teaspoonful of powder of ipecacuanha, or a tablespoonful of mustard ; 
each dissolved or mixed in a large draught of warm water. Vomiting 
must be insured by repeated doses. If swallowing be impossible, the 
stomach pump must be used ; introducing the flexible tube through the 
pharynx into the stomach, and washing it out by gently injecting, and 
then withdrawing, half a pint of water at a time by a syringe. 

If any antidote for opium or its alkaloids has given reason for con- 
fidence, it is belladonna. Facts fully warrant its administration. 
Twenty minims of tincture of belladonna may, in opiate narcotism, be 
given every hour. Strong coffee is an older remedy, upon a similar 
indication. To counteract the comatose tendency, also, cold water 
may be dashed or poured at intervals over the head and face ; strong 
sinapisms may be applied to the back, epigastrium, and limbs ; or the 
patient, if able, may be made to walk about ; or flagellation, with the 
hand or a wet towel, may be used for the same end. 

In the extremest cases, faradization may be used ; the interrupted 
current being applied to the spine and chest. Galvano-puncture is 
justifiable if other means fail ; the fine needle being made to penetrate 
so as to reach the diaphragm, for the immediate stimulation of its 
muscular power. The needle for such a purpose should be of soft- 
tempered steel, platinized ; fine and sound, well polished, three or four 
inches long, with a lance-shaped point. Artificial respiration is resorted 
to in some cases. (See Asphyxia.) 

Belladonna or atropia may be antagonized by opium, upon the same 
kind of evidence as that just alluded to. The antidotal action is not 
chemical, but physiological. Stramonium (Jamestown weed) must 
also stand in the same relation to opium ; and so must hyoscyamus, 
perhaps in a less positive degree. 

Unclassified Poisons.— Prussic Acid. For this no certain antidote 
exists ; and the arrest of life is so sudden as scarcely to allow its use, 
if we had one. T. and T. C. Smith, English chemists, assert that they 
have proved the following recipe to be antidotal for it : — 



BITES OF SERPENTS — ASPHYXIA. 367 

" Take of liquor of perchloride of iron 57 minims; protosulphate of 
iron in crystals, pure, 25 grains ; as much water as will make a solution 
of a proto-sesqui-salt of iron, measuring about half an ounce. Dissolve, 
on the other hand, 77 grains of crystallized carbonate of soda in about 
half an ounce of water. These quantities destroy the poisonous action 
of between 100 and 200 drops of prussic acid, officinal strength, by 
giving first the one liquid, and then the other. For cyanide of potas- 
sium the antidote is the same except that the solution of proto-sesqui- 
salt of iron is to be used without the soda solution ; the hydrocyanic 
acid having been already combined with an alkaline substance. The 
use of the soda would, however, not be injurious. The quantities 
given, as above, would decompose 35 grains of cyanide of potassium." 

Cold affusion, chlorine ivater, and ammonia are the older measures 
advised for prussic acid poisoning. 

Aconite, digitalis, hemlock, ergot, tobacco, lobelia, veratrum virid°, 
aniline, strychnia, poisonous fungi, &c, have no known antidotes. 
Emetics should be promptly given when any of them is known to have 
been taken. Castor oil is also recommended, especially for those least 
depressing in their action. Aconite, lobelia and tobacco are the most 
powerfully sedative. Animal charcoal is advised, to absorb and render 
innoxious organic poisons in the stomach ; teaspoonful doses should 
be given, repeatedly. For the spasms caused by strychnia or mix 
vomica, inhalation of chloroform is thought to be beneficial. For to- 
bacco, lobelia, aconite, digitalis, or veratrun viride, taken poisonously, 
brandy or whisky as a stimulant would seem to be indicated. 

BITES OF SERPENTS. 

When a person is bitten by a venomous serpent, or by a rabid dog 
or other animal, the part should be, if accessible, at once sucked 
strongly with the mouth, to avoid loss of time. Wash it then 
thoroughly with hot water. Apply a cupping-glass for some minutes. 
Cauterize it with caustic potassa ; or, if practicable, excise the part 
bitten. Aqua ammonias is useful also as a local antidote 1 for snake- 
poison, and for that of venomous insects ; and so is fluid extract of 
serpentaria. 

Should symptoms of poisoning have already followed the bite of a 
rattlesnake, experience seems to countenance the antagonistic and 
supporting use of whisky. Cures are said to have occurred, in several 
instances, where the person bitten drank large amounts of this ; intoxi- 
cation not being produced, on account of the counteracting impression 
of the poison upon the system. 

ASPHYXIA. 

Whether from drowning, breathing coal-gas in an unventilated 
apartment, or excessive inhalation of chloroform, &c, the treatment 
for suspended animation must be essentially the same in principle. 

1 Bibron's antidote consists of bromine oijss ; iodide of potassium, gr. ij ; 
corrosive sublimate gr. j j dilute alcohol f5xxx. Dose, f5J, in wine or brandy, 
p. r. n. 



368 FORMULA. 

First, loosen everything about the neck. Draw the tongue forward 
and clear the mouth. Laying the patient upon the back, let both 
arms be raised (Sylvester) as far as possible above the head, and then 
brought down again ; this should be repeated at least twenty times a 
minute ; that is, faster than the ordinary rate of breathing. Blowing 
into the mouth or nostrils, with or without a trachea-tube, is available 
sometimes, especially in a child ; at the same time, when oxygen gas 
can be obtained (as, of course, it very rarely can), a jet of it may be 
used. 

Passing a vial of solution of ammonia at intervals under the nostrils 
will aid to excite the nerve-centres. Eubbing the limbs and trunk, 
vigorously, and chiefly towards the heart, to hurry the venous circu- 
lation, is useful. So, also, is the application of mustard, or friction 
with red pepper and brandy or whisky. Hot bottles may be applied 
to the feet and legs. Excessive heat will not be expedient before 
respiration is established; but moderate warmth always promotes 
vitality. The expedient of applying a red hot iron, momentarily, to 
the epigastrium or the back of the neck, for intensely stimulant effect, 
is not unreasonable in idea. Galvanism may be employed in any case 
of suspended animation. 



FORMULA. 

Every physician should acquire such knowledge of the remedies he 
employs as to prescribe and combine them according to the indications 
of particular cases ; not by the routine of names of diseases ; and still 
less by fixed recipes or formulae. While this is obvious, all routine 
being, as such, bad practice, a beginner may yet find advantage, and 
a practitioner of experience may occasionally save time, by having 
some exemplars of prescriptions at hand for reference. A selection 
of such examples is therefore given. Many of the recipes are original, 
and all are carefully made ; the number being very much less ex- 
tended than it might easily have been, in accordance with the princi- 
ple above laid down. Those first given will for convenience, follow 
mainly the order of the diseases for which they are most likely to be 
required, as those diseases are treated of in Part II. of this volume. 

The doses in these prescriptions, unless otherwise stated, are in- 
tended for adults. To reduce the dose of any drug (except narcotics, 
and, perhaps, mercurials) according to the age of a child, the rule 
suffices, to divide the dose for an adult, in proportion to the number 
of years of the child's age, increased by 12. Thus, for a child of two 
years, the dose will be T \ (2 divided by 2 + 12) or 4th of that for an 
adult ; for a child of three years (3 divided by 3 + 12 = 15), T 3 5 or jth, 
&c. Opium and other narcotics act more powerfully, in proportion, 
upon children ; so that their dose should be reduced in a greater 
degree. Calomel and other mercurials do not so readily affect the 
glands, at least, in children, as in adults. 

Simplicity is made an especial aim in the following formulae ; con- 
sidering, in this, the advantage rather of the tyro than of the practi- 
tioner of experience. 



FORMULA. 369 



MEDICINES REFERRED TO IN PART II. 

1. Solution of Tartar Emetic. 

R. — Tartrate of Antimony and Potassa, two grains ; Water, four fluid- 
ounces ; dissolve. Take one or two teaspoonfuls every two, three, or 
four hours. 

In active pneumonia, pleurisy, severe bronchitis, pericarditis, etc. 

2. Quinine Solution, 

]£. — Sulphate of Quinine, half a drachm ; Aromatic Sulphuric Acid 
(elixir of vitriol), a fluidrachm and a half; Oil of Cloves, four drops ; 
Mucilage of Gum Arabic, a fluidounce ; Peppermint Water, enough to 
make in all four fluidounces ; mix. Take a teaspoonful or two every 
three or four hours, in asthenic pneumonia, low fevers, etc., as a supporting 
remedy ; larger doses, or the same at shorter intervals, for intermittent 
fever, etc. 

3. Ammonia Mixture. 

R. — Carbonate of Ammonia, one drachm ; Mucilage of Gum Arabic, 
four fluidounces ; Orange-flower Water, or Peppermint Water, two fluid- 
ounces ; mix. Dose, a dessert-spoonful, or tablespoonful, every hour. 

In cases of general prostration ; typhoid pneumonia, influenza of old 
people, etc. 

4. Nitrate of Potassa. 

R. — Nitrate of Potassa, two drachms; Powder of Gum Arabic, or 
White Sugar, two drachms ; divide into twelve papers. Take one every 
two or three hours. 

In mild pneumonia, bronchitis, etc. 

5. Wine of Ipecacuanha. 

R. — Wine of Ipecacuanha, half a fluidounce. Take twenty drops 
every two or three hours, in a tablespoonful of water. 
In tonsillitis, erysipelas, etc. 

6. Calomel, Ipecacuanha, and Nitre. 

R. — Calomel and Ipecacuanha Powder, each six grains; Nitrate of 
Potassa, half a drachm, or a drachm ; mix, and divide into twelve pow- 
ders. Take one powder every three hours. 

In pneumonia, pleurisy, etc. 

7. Solution of Acetate of Ammonia. 

Dissolve two scruples of Carbonate of Ammonia in four fluidounces of 
Water, and add pure Vinegar, slowly, until it ceases to effervesce. This 
will substitute the " liquor ammonias acetatis" or spiritus Mindereri. 
Dose, a dessert-spoonful, or a tablespoonful, with as much of water, 
every two or three hours ; in any febrile affection where purging is not 
desirable, as a diaphoretic. 



310 FORMULA. 



8. Acetate of Potassa. 

5. — Acetate of Potassa, five drachms and a half; Sweet Spirits of Nitre, 
two fluidrachms ; Water, enough to make eight fluidounces ; dissolve. 
Take a tablespoonful every three or four hours. 

In feeble cases of pneumonia, instead of tartar emetic ; also, as diuretic, 
in pleuritic effusion, etc. 

9. Calomel, Opium, and Tartar Emetic. 

R. — Calomel, six grains ; Opium, three to six grains ; Tartar Emetic, 
a grain and a half ; mix, and divide into twelve powders. Take one 
every three or four hours, in water. 

In acute pleurisy, 

10. Squills and Digitalis. 

R. — Powder of Squills, half a drachm ; Powder of Digitalis, eight to 
sixteen grains ; mix, and divide into sixteen pills. Take one thrice 
daily. 

In pleuritic effusion. 

11. Compound Spirits of Juniper. 

R.— Compound Spirit of Juniper, two fluidounces. Take one or two 
teaspoonfuls thrice daily, in a wineglassful of water. 

As diuretic, in pleuritic effusion, etc. ; especially in feeble cases. 

12. Juniper Infusion and Cream of Tartar. 

R. — Bruised Juniper Berries, one ounce ; infuse for two hours in a pint 
of hot water ; pour off, and add a tablespoonful or two of Bitartrate of 
Potassa. Stir and drink in portions through the day. 

In dropsical effusion of any kind. 

13. Squills, Nitre, and Digitalis. 

R. — Nitrate of Potassa, two drachms ; Oxymel of Squills, a fluid- 
ounce ; Tincture of Digitalis, half a fluidrachm ; Vinegar, a tablespoonful ; 
Sugar and Gum Arabic, each two drachms ; Water enough to make in all 
six fluidounces ; mix. Take a tablespoonful every three hours . 

In acute bronchitis, influenza, etc. 

14. Squills and Tartar Emetic. 

5. — Tartar Emetic, one grain ; Syrup of Squills, four ounces ; mix. 
Take a teaspoonful every three or four hoars. 
In bronchitis, with dry cough. 

15. Squills and Paregoric. 

R. — Syrup of Squills, three fluidounces ; Paregoric (Camphorated 
Tincture of Opium), one fluidounce ; mix. Take a teaspoonful three 
or four times daily ; or two teaspoonfuls at night. 

In bronchitis or influenza, after loosening the cough. 



FORMULA. 3U 



16. Muriate of Ammonia. 

R. — Muriate of Ammonia, three drachms ; Mucilage of Gum Arabic, 
four fluidounces ; mix. Take a tablespoonful four times daily. 
In chronic bronchitis. 

17. Copaiba Mixture. 

I£. — Balsam of Copaiba, three fluidrachms ; Compound Spirit of 
Lavender, two fluidrachms ; White Sugar and Gum Arabic, each two 
drachms ; Water, enough to make six fluidounces ; mix. Take a table- 
spoonful thrice daily. 

18. Lobelia and Ipecacuanha. 

I£. — Tincture of Lobelia, and Wine of Ipecacuanha, each half a fluid- 
ounce ; mix. Take one half teaspoonful every half hour until expectora- 
tion or nausea occurs. 

In asthma. 

19. Mush Mixture. 

^. — Musk, two scruples ; Syrup of Orange, one fluidounce ; Mucilage 
of Gum Arabic, three fluidounces ; mix. Take a tablespoonful every 
two or three hours. 

In spasmodic cough of any kind ; or other spasmodic affections. 

20. Hydrocyanic Acid. 

R. — Dilute Hydrocyanic Acid, sixteen drops ; Syrup of Wild Cherry, 
and Camphor Water, each one fluidounce ; mix. Dose, a teaspoonful 
every two or three hours. 

In violent, troublesome cough. 

21. Nitromuriatic Acid. 

fy.. — Nitromuriatic Acid, half a fluidounce (or, Nitric Acid, one flui- 
drachm and a half; Muriatic Acid, two arid a half fluidrachms). Take 
three or four drops twice or thrice daily, with water, in a glass. 

In general or gastric debility, chronic or subacute jaundice, etc. 

22. Bromide of Potassium. 

fy.. — Bromide of Potassium, half an ounce ; Peppermint or Cinnamon 
Water, or Pure Water, six fluidounces. Dose, from a dessert-spoonful 
to a tablespoonful. 

In insomnia, hysteria, spermatorrhoea, etc. 

23. Citrate of Iron. 

]J. — Citrate of Iron, two drachms ; Orange-flower Water, five ounces 
and a half; Simple Syrup, half an ounce. Take from a teaspoonful to 
a tablespoonful thrice daily, before or after meals. 

For ancemic children. 

24. Ipecacuanha and Alum. 

ty. — Powder of Ipecac, and Powder of Alum, each half a teaspoonful ; 
mix with water. Repeat in ten minutes if it does not vomit. 
In threatening croup. 



372 FORMULA. 



25. Calomel and Nitrate of Potassa, 

I£. — Calomel, six to twelve grains ; Nitrate of Potassa, one drachm ; 
Sugar, one scruple ; mix, and divide into twelve powders. Take one 
every three hours. 

In inflammatory croup. 

26. Nitrate of Silver Solution. 

]J. — Nitrate of Silver, five to ten grains ; Rose-water, or Distilled 
Water, half a fluidounce ; dissolve. Apply with camel's hair pencil to 
the throat, in membranous croup, or scarlet fever. 

27. Tincture of Aconite Root. 

fy. — Saturated Tincture of Aconite Root, one teaspoonful. To be 
rubbed gently into the skin, in neuralgia. 

28. Chloroform Liniment. 

I£. — Chloroform, three fluidounces ; Olive Oil, four fluidounces ; mix. 
Pure chloroform, prevented from evaporating by oiled silk, or a watch 
glass, acts as a strong rubefacient ; burning like mustard. 

29. Ointment of Ver atria. 

5-. — Veratria, ten to twenty grains ; Pure Lard, one ounce ; mix. 
In severe neuralgia ; applied to the part. 

30. Cod-Liver Oil. 

I£. — Cod-Liver Oil, Syrup of Ginger, and Mucilage of Gum Arabic, 
each two fluidounces ; Oil of Cloves, six drops ; mix. Take a table- 
spoonful three or four times daily. 

In wasting diseases. 

31. Cod-Liver Oil and Glycerin. 

I£. — Cod-Liver Oil and Glycerin, each two fluidounces ; Gum Arabic, 
two drachms ; Oil of Bitter Almonds, two drops ; Oil of Cloves, twelve 
drops. Take a tablespoonful thrice daily. 

32. Cod-Liver Oil, Glycerin, Iron, and Quinine. 

fy. — Take of Citrate of Ammonia, Iron, and Quinine, ten grains ; Cod- 
Liver Oil and Glycerin, each two fluidounces ; mix. 
Dose, a tablespoonful. 

33. Iodide of Iron. 

I£. — Liquor of the Iodide of Iron, half a fluidounce. Take twelve to 
twenty drops, in water, thrice daily. 
In anozmia, scrofula, etc. 

34. Tincture of Nux Vomica. 

fy. — Tincture of Nux Vomica, half a fluidounce. Take from ten to 
thirty drops, thrice daily. 

In nervous debility, aggravated dyspepsia, etc. 



FORMULAE. SIS 

35. Wild Cherry and Lactucarium. 

"fy. — Syrup of Wild Cherry, and Syrup of Lactucarium, each two fluid- 
ounces ; mix. Take a dessert-spoonful or two, at night, or one or two 
teaspoonfuls in the daytime. 

In frequent and troublesome cough; as in phthisis. 

36. Hoffmann's Anodyne, Squills, and Morphia. 

R. — Syrup of Squills, a fluidounce and a half; Hoffmann's Anodyne 
(Compound Spirit of Ether) and Solution of Morphia (one grain in the 
ounce) each a fluidounce ; Camphor Water and Mucilage Gum Arabic, of 
each a fluidounce and a quarter ; mix. Dose, from a teaspoonful to a 
tablespoonful. 

In troublesome coughs. 

37. Carbonate of Potassa and Nitre. 

R. — Carbonate of Potassa and Nitrate of Potassa, each two drachms 
and a half ; Water, eight fluidounces ; dissolve. Take a tablespoonful 
thrice daily. 

In gouty attacks. 

38. Digitalis, Squills, Sf-c. 

R. — Citrate of Potassa, two hundred grains ; Tincture of Squills, two 
fluidrachms ; Wine of Colchicum Root, one fluidrachm ; Liquor of Acetate 
of Ammonia, two fluidrachms ; Infusion of Digitalis, two fluidounces ; 
Peppermint Water, enough to make eight fluidounces ; mix. Take half 
a wineglassful thrice daily. 

In dropsical effusions. 

39. Cream of Tartar and Dandelion. 

R. — Take of Bitartrate of Potassa, an ounce ; Extract of Taraxacum, 
half a drachm ; Decoction of Taraxacum, eight fluidounces ; mix. Take 
half a wineglassful two or three times daily. 

In dropsy or jaundice. 

40. Cider Mixture. 

R. — Bruised Juniper Berries, Mustard Seed, and Ginger, each half an 
ounce ; Bruised Horseradish and Parsley Root, each an ounce ; sound 
old Cider, a quart ; infuse. Dose, a wineglassful thrice daily. 

In dropsy. 

41. Acetate of Lead Pills. 

R. — Acetate of Lead, half a drachm ; Opium, five grains ; Conserve 
of Roses, or Crumb of Bread, a sufficient quantity; mix, and divide 
into twenty pills. Take one thrice daily. 

In hypertrophy of the heart. 

42. Digitalis. 

R. — Powder of Digitalis, twelve grains; divide into twelve pills. 
Take one thrice daily. 

In cases of over-rapid action of the heart, 
32 



374 FORMULA. 

43. Digitalis. 

R. — Tincture of Digitalis, half a fluidounce. Take ten drops thrice 
daily, in water. 
As above, 

44. Veratrum Viride. 

R. — Norwood's Tincture of Veratrum Viride, half a fluidounce. 
Take from two to five drops every three or four hours. If nausea or 
prostration follow, withdraw it or diminish the dose. 

In hypertrophy of the heart and inflammatory fetter, 

45. Colchicum and Magnesia. 

R. — Wine of Colchicum Root, one fluidrachm ; Husband's Magnesia, 
one drachm ; Peppermint Water, four fluidounces ; mix. Take a table- 
spoonful thrice daily. 

In gout and gouty rheumatism. 

46. Colchicum and Alkalies. 

R. — Wine of Colchicum Root, one fluidrachm ; Bicarbonate of Potassa 
and Rochelle Salts, each two drachms and a half; Peppermint Water, 
four fluidounces ; mix. Take a tablespoonful thrice daily. 

In gout and gouty rheumatism. 

47. Hoffmann's Anodyne, Ammonia, and Soda. 

R. — Bicarbonate of Soda, four scruples ; Aromatic Spirit of Ammonia, 
one fluidrachm ; Compound Spirit of Ether, one fluidounce ; Compound 
Tincture of Cardamom, three fluidrachms ; Camphor Water and Muci- 
lage of Gum Arabic, each a fluidounce and a quarter ; mix. Take a 
dessert-spoonful or tablespoonful at once. 

In angina pectoris, or gout of the stomach or heart. 

48. Warner's Cordial and Laudanum. 

R. —Tincture of Rhubarb and Senna, a fluidounce and a half; Syrup 
of Ginger, three fluidrachms ; Laudanum, one fluidrachm ; mix. Take 
a teaspoonful at once, in hot water. 

In angina pectoris, or spasmodic gout. 

49. Chloroform, Hoffmann's Anodyne, Spc. 

R.— Chloroform and Aromatic Spirit of Ammonia, each two flui- 
drachms ; Hoffmann's Anodyne and Paregoric, each half an ounce ; Mu- 
cilage of Gum Arabic, half an ounce ; mix. Take a teaspoonful at once. 

In angina pectoris, retrocedent gout, frc. 

50. Glycerin and Rose- Water. 

R. — Glycerin, one part ; Rose-water, five parts ; mix. Use as a lotion 
for the skin, or a mouth-wash. 

51. Prepared Chalk and Gum Arabic. 

R. — Equal parts of finely powdered prepared chalk, and powder of 
Gum Arabic ; mix. 

Apply to ulcerated places in the mouth. 



FORMULAE. 315 



52. Borax, Myrrh, frc. 

R. — Biborate of Soda, two drachms ; Powdered Myrrh, one drachm ; 
Water, six fluidounces ; mix. 
Use as mouth-wash. 

53. Sulphate of Zinc and Rose-Water. 

R. — Sulphate of Zinc, from two to ten or twenty grains ; Rose-water, 
a fluidounce ; dissolve. 

Use as mouth-wash, with care, in severe cases. 

54. Chlorate of Potassa. 

R. — Chlorate of Potassa, half an ounce; Water, six fluidounces; 
dissolve. Take a tablespoonful every three or four hours. 
In ulceration of the mouth or throat, diphtheria, etc. 

55. Muriatic Add and Honey. 

R. — One part of Muriatic Acid and two parts of Honey ; mix. To be 
applied to the throat in diphtheria, with a soft sponge, firmly fastened 
to a (probang) piece of whalebone. 

In diphtheria. 

56. Tincture of Chloride of Iron. 

R. — Tincture of Chloride of Iron, half a fluidounce. Take from ten 
to thirty drops thrice daily, in water. 

In ancemia , diphtheria, metrorrhagia, leucorrhaa. asthenic erysipelas, etc. 

57. Chlorinated Soda and Glycerin. 

fy. — Labarraque's Solution of Chlorinated Soda, one fluidrachm 
Bower's Glycerin, and Water, each two fluidounces ; mix. 
Use as mouth-wash, in gangrcena oris. 

58. Creasote and Glycerin. 

R. — Creasote, two or three drops ; Bower's Glycerin, and Water, each 
half a fluidounce : mix. 

Use as mouth-wash, in cancrum or gangr&na oris, or severe aphtha or 
thrush. 

59. Alum, Brandy, and Water. 

R. — Alum one drachm, dissolve in six fluidounces of water ; add two 
fluidounces of brandy. 

To wash the mouth in salivation. 

60. Tannic Acid Solution. 

fy. — Tannin, ten to thirty grains ; Water, a fluidounce ; dissolve. 
To be applied with a hair-pencil, to enlarged tonsils, etc. 

6 1 . Iodide of Po ta ssi u m . 

R. — Iodide of Potassium, one to two drachm3 ; Cinnamon or Pepper- 
mint Water, six fluidounces ; dissolve. Take a tablespoonful thrice 
daily. 

As alterative in syphilitic rheumatism, and in many other affections. 



376 FORMULAE. 



62. Nitrate of Silver Pills. 

]$. — Nitrate of Silver, five grains; Opium, two grains and a half; 
mix, and divide into twenty pills. Take one thrice daily. 
In chronic gastritis. 

63. Subnitrate of Bismuth. 

R. — Subnitrate of Bismuth, one to three drachms ; divide into twelve 
powders. Take one three or four times daily, in water. 
In gastric or intestinal irritation. 

64. Lime-water and Milk. 

Mix together equal parts of clear Lime-water and good Milk. Take a 
dessert-spoonful or tablespoonful of the mixture at once. 

To check vomiting, or give nourishment when the stomach is irritable. 

65. Effervescing Draught. 

Dissolve two drachms and a half of Bicarbonate of Potassa in four 
fluidounces of Water. Pour out, for administration, a tablespoonful of 
this solution, and add to it a tablespoonful of water. Then add a table- 
spoonful of fresh Lemon -juice ; or of a solution containing two drachms 
of Citric Acid in four fluidounces of Water. 

In fever ', with irritability of stomach ; also, in sea-sickness. 

66. Cardamom and Potassa Mixture. s 

R. — Bicarbonate of Potassa, one drachm ; Compound Tincture of Car- 
damom, a fluidounce ; Syrup of Ginger, two fluidrachms ; Orange- 
flower Water, enough to make four fluidounces ; mix. Take a dessert- 
spoonful at once. 

To relieve nausea and vomiting. 

67. Ammonia, Soda, and Morphia. 

R. — Bicarbonate of Soda, four scruples ; Aromatic Spirit of Ammonia, 
one fluidrachm ; Solution of Morphia, two fluidrachms ; Cinnamon 
Water, enough to make four fluidounces. Take one or two teaspoon- 
fuls at once. 

For vomiting. 

68. Creasote, Soda, and Morphia. 

R . — Creasote, eight drops ; Bichlorate of Soda, one drachm ; Solution 
of Morphia, a fluidrachm and a half; Peppermint Water, enough to 
make four fluidounces ; mix. Take one or two teaspoonfuls at once. 

For vomiting. 

69. Calomel Powders. 

R. — Calomel, two grains ; divide into eight powders. Take one every 
two hours. 
For vomiting. 

70. Spice Poultice. 

R. — Of Powdered Cloves, Ginger, and Cinnamon, each one or two tea- 
spoonfuls ; Wheat Flour, a tablesponful ; Brandy, enough to make a 



FORMULAE. 377 

mass moist enough to spread upon thiu, soft flannel. Double the flannel 
over it. and apply it to the abdomen. 
In obstinate vomiting, etc. 

71. Nux Vomica, Iron, and Quinine, 

R. — Pill of Carbonate of Iron (Valleix's Mass), two scruples (or, 
Quevenne's Metallic Iron, per hydrogen, one scruple) ; Sulphate of 
Quinia, one scruple ; Alcoholic Extract of Nux Vomica, five grains ; mix, 
and divide into twenty pills. Take one thrice daily. 

In prolonged atonic dyspepsia, general debility, or ganglionic cachexia. 

72. Tincture of Gentian and Rhubarb. 

I£. — Compound Tincture of Gentian, and Tincture of Rhubarb, each 
two fluidounces ; mix. Take two teaspoonfuls before each meal. 
In dyspepsia. 

73. Gentian and Rhubarb Pills. 

R. — Extract of Gentian, and Powder of Rhubarb Root, each half a 
drachm ; mix and divide into twenty pills. Take one or two thrice 
daily. 

In dyspepsia, flatulence, or tendency to colic. 

74. Gentian, Rhubarb, and Blue Mass. 

I£. — Extract of Gentian, and Powder of Rhubarb, each half a drachm ; 
Blue Mass, four grains ; mix and divide into twenty pills. Take one 
three or four times daily, for a few days. 

To prevent recurring bilious colic or sick headache. 

75. Rhubarb Pills. 

I£. — Rhubarb Root, and Castile Soap, each half a drachm ; Oil of 
Anise, four drops ; mix, and divide into twenty pills. Take one or two 
as required. 

For slight constipation. 

76. Rhubarb and Colocynth. 

fy. — Rhubarb, and Compound Extract of Colocynth, each half a drachm ; 
mix, and divide into twenty pills. Take one or two as required. 
For constipation. 

77. Rhubarb and Aloes, frc. 

ty. — Rhubarb, two scruples ; Aloes, one scruple ; Extract of Nux 
Vomica, four grains ; mix, and divide into twenty pills. Take one as 
required. 

For obstinate constipation. 

78. Carminative Mixture. 

jj,. — Bicarbonate of Soda, one drachm ; Compound Tincture of Carda- 
mom, one fluidounce ; Spirit of Camphor, one fiuidrachm (or, Paregoric, 
half a fluidounce) ; Spiced Syrup of Rhubarb, half a fluidounce ; 
Peppermint Water, enough to make four fluidounces. Take a teaspoon- 
ful at once. 

32* 



378 FORMULAE. 

79. Oil of Cajuput. 

R. — Oil of Cajuput, half a fluidrachm ; Compound Spirit of Lavender, 
half a fluidounce ; Syrup of Ginger, two fluidrachms ; Mucilage of Gum 
Arabic, enough to make two fluidounces. Take a dessert-spoonful at 
once. 

For flatulent pain in the bowels. 

80. Ammonio-ferric Alum* 

R. — Ammonio-ferric Alum, two scruples ; Cinnamon Water, four fluid 
ounces ; dissolve. Take a tablespoonful every two or three hours. 
An excellent tonic astringent. 

81. Creasote Pills. 

]£. — Creasote, twenty drops ; Conserve of Roses (or Extract of Gentian), 
one drachm ; mix, and divide into twenty pills. Take one every two, 
three, or four hours. 

As astringent, in hmmatemesis, ulcer of stomach, etc. 

82. Podophyllum, etc. 

]£. — Resin of Podophyllum, two grains ; Fluid Extract of Rhubarb 
and Fluid Extract of Senna, each a fluidounce ; Oil of Cloves, four drops ; 
Syrup of Ginger, half a fluidounce ; Mucilage of Gum Arabic, enough to 
make four fluidounces. Dose for an adult, a tablespoonful. 

For constipation, 

83. Suppository of Soap. 

Cut a piece of good Yellow Soap to the shape, and rather less than 
the size, of the last joint of the little finger. Dip it in Castor Oil, Olive 
Oil, or Lard, and introduce it within the rectum. 

To act upon the bowels, instead of an enema. 

84. Nux Vomica, Colocynth, and Soap. 

]£. — Compound Extract of Colocynth and White Soap, each half a 
drachm ; Extract of Nux Vomica, five grains ; mix, and divide into 
twenty pills. Take one night and morning. 

For torpor of the bowels. 

85. Aloes, Rhubarb, and Belladonna. 

I£. — Rhubarb and Aloes, each half a drachm; Extract of Belladonna, 
three grains ; Oil of Cloves, three drops ; mix, and divide into twenty 
pills. Take one twice daily. 

For habitual constipation. 

86. Calomel and Opium Pills. 

I£. — Calomel and Opium, each six grains ; mix, and divide into twelve 
pills. Take one every two, three, or four hours. 
In peritonitis, bilious colic, etc. 

87. Pills of Opium and Ipecacuanha. 

I£. — Powder of Opium and Powder of Ipecacuanha, each six grains; 
mix, and divide into twelve pills. Take one every three hours. 
In typhlitis. 



FORMULAE. 379 



88. Cerate of Carbonate of Lead. 

fy. — Carbonate of Lead, two drachms ; Simple Cerate, one ounce ; mix. 
For external use, in chronic ophthalmia, periostitis, hcemorrhoids, etc. 

89. Aromatics, etc., for Colic. 

I£. — Aromatic Spirit of Ammonia and Spirit of Camphor, each a flui- 
drachm ; Tincture of Ginger, two fiuidrachms ; Bicarbonate of Soda, four 
scruples ; Peppermint Water, enough to make four fluidounces. Dose, 
a tablespoonful. 

90. Carminative Anodyne. 

fy. — Spiced Syrup of Rhubarb, Compound Tincture of Cardamom, 
Paregoric, and Cinnamon Water, each a fluidounce ; mix. Dose, from 
a dessert-spoonful to a tablespoonful. 

For crapulent colic. 

91. Chloroform Mixture. 

R. — Chloroform, a fluidounce ; Camphor Water, Peppermint Water, 
and Mucilage of Gum Arabic, each a fluidounce ; mix. Dose, from a 
teaspoonful to a tablespoonful, repeated cautiously. 

For colic, etc. 

92. Chloroform Paregoric — No. 1. 

I£. — Chloroform, Laudanum, Spirit of Camphor, and Aromatic Spirit 
of Ammonia, each a fluidrachm and a half ; Creasote, three drops ; Oil 
of Cinnamon, eight drops ; Alcohol, two fiuidrachms ; mix. Dose, from 
ten drops to half a teaspoonful, in water. 

In cholera. 

93. Chloroform Paregoric — No. 2. 

]£. — Chloroform, two fiuidrachms ; Spirit of Camphor, a fluidrachm 
and a half ; Laudanum, a fluidrachm ; Oil of Cinnamon, five drops ; 
Alcohol, three and a half fiuidrachms ; mix. Dose, ten drops to half a 
teaspoonful, in water. 

94. Carminative for Infants. 

]J. — Bicarbonate of Soda, half a drachm ; Aromatic Spirit of Ammonia, 
half a fluidrachm ; Solution of Morphia, half a fluidrachm ; Syrup of 
Ginger, half a fluidounce ; Camphor Water, enough to make two fluid- 
ounces ; mix. Dose, a teaspoonful, repeated if necessary. 

In colic. 

95. Podophyllum, Rhubarb, etc, 

^. — Resin of Podophyllum, one grain ; Simple Syrup of Rhubarb, a 
fluidounce ; Oil of Fennel, one drop ; mix. Dose, ten drops to a tea- 
spoonful. 

For constipation in infants. 

96. Castor Oil and Spiced Syrup of Rhubarb. 

Mix one tablespoonful of Castor Oil thoroughly with two tablespoon- 
fuls of Spiced Syrup of Rhubarb ; and administer it immediately after 
mixture. This is the least disagreeable way of taking castor oil. 



380 FORMULA. 



97. Castor Oil and Laudanum. 

To the above prescription, add ten, twenty, or thirty drops of Laudanum. 
Useful in incipient acute dysentery. 

98. Assafoztida Mixture, 

I£. — Rub one drachm of Assafoetida gradually with four ounces of 
Water, until thoroughly mixed. Then add two fluidounces of Syrup of 
Ginger. 

Dose for a child, a teaspoonful. 

99. Magnesia and Ammonia Mixture. 

fy. — Best Magnesia (Husband's or Ellis'), a drachm ; Aromatic Spirit 
of Ammonia, a fluidrachm ; Peppermint Water, four fluidounces ; mix. 
To be shaken before administration. Take a teaspoonful every half 
hour. 

In common summer cholera morbus. 

Half a fluidounce of Paregoric may be added to the above, if there is 
much purging. 

100. Chloroform and Camphor. 

I£. — Chloroform, half a troyounce ; Camphor, one drachm ; the yolk of 
one Egg ; Water, six fluidounces. Rub the yolk in a mortar, first by 
itself, then with the Camphor, previously dissolved in the Chloroform, 
and lastly, with the Water, gradually added. This is the " Mixture of 
Chloroform" of the United States Pharmacopoeia. 

Dose, from a teaspoonful to a tablespoonful. 

101. Spiced Rhubarb and Magnesia. 

fy. — Spiced Syrup of Rhubarb, half a fluidounce ; Magnesia (Hus- 
band's), fifteen grains ; Cinnamon Water and Camphor Water, each two 
fluidrachms ; mix. Take in two doses, three hours apart. 

As a corrective in slight diarrhoea. 

102. Chalk Mixture. 

fy. — Prepared Chalk, two drachms ; White Sugar and Gum Arabic, 
each a drachm and a half; Tincture of Kino, two fluidrachms and a half; 
Laudanum, twenty to forty drops ; Peppermint Water, enough to make 
six fluidounces ; mix. Dose, a tablespoonful. 

In diarrhoea. 

103. Camphor Mixture. 

I£. — Compound Spirits of Lavender, a fluidounce ; Spirit of Camphor, 
a fluidrachm ; Laudanum, half a fluidrachm ; Sugar and Gum Arabic, 
each a drachm and a half ; Cinnamon Water, enough to make six fluid- 
ounces ; mix. Dose, a tablespoonful once in three hours. 

In diarrhoea. 

104. Lead and Morphia Mixture. 

1^. — Acetate of Lead, eight to sixteen grains ; Acetate of Morphia, one 
grain ; Gum Arabic, two drachms ; Cinnamon Water, enough to make 
eight fluidounces ; mix. Take a teaspoonful every three or four hours. 

In obstinate diarrhoea. 






FORMULAE. 381 



105. Catechu and Paregoric. 

I£. — Tincture of Catechu and Paregoric, each half a fluidounce ; mix. 
Take a teaspoonful every three or four hours. 
In severe diarrhoea. 

106. Tannic Acid and Opium, 

]J. — Tannic Acid, thirty-six grains ; Powder of Opium, three to four 
grains ; mix, and divide into twelve pills. Take one every three or four 
hours. 

To check diarrhoea. 

107. Calomel, Soda, and Ginger. 

5. — Calomel, two grains ; Bicarbonate of Soda, one scruple ; Powder 
of Ginger, twelve grains ; mix, and divide into twelve powders. Give 
one three or four times daily. 

In incipient cholera infantum. 

108. Mercury with Chalk, and Cinnamon. 

]£. — Mercury with Chalk, and Powder of Cinnamon, each twelve 
grains ; mix, and divide into twelve powders. Give one thrice daily. 
In the early stage of cholera infantum. 

109. Ammonia, Rhubarb, and Paregoric. 

I£. — Aromatic Spirit of Ammonia, twenty-five drops ; Paregoric, half a 
fluidrachm to a fluidrachm ; Spiced Syrup of Rhubarb, a fluidounce ; 
Peppermint Water, enough to make two fluidounces ; mix. Give a tea- 
spoonful every three hours. 

In cholera infantum. 

110. Rhatany and Paregoric. 

]£. — Tincture of Krameria and Paregoric, each a fluidrachm ; Sugar 
and Gum Arabic, each half a drachm ; Cinnamon Water, diluted, enough 
to make two fluidounces ; mix. Give a teaspoonful every two, three, or 
four hours. 

To check the diarrhoea of cholera infantum. 

111. Blue Mass and Ipecacuanha. 

ty.. — Blue Mass, twelve grains ; Powder of Ipecacuanha, six to twelve 
grains ; e mix, and divide into twelve pills. Take one every three hours. 
In incipient dysentery. 

112. Blue Mass, Ipecacuanha, and Camphor. 

I£. — Blue Mass, eight grains; Ipecacuanha, six grains; Camphor, 
twelve grains ; mix, and divide into twelve pills. Take one e^ery 
three hours. 

In the early stage of dysentery. 



382 FORMULA. 

113. Camphor, Ipecac, and Opium, 

R. — Camphor, eighteen grains ; Ipecacuanha, six grains ; Opium, three 
to six grains ; mix, and divide into twelve pills. Take one every three 
or four hours. 

In dysentery, 

114. Acetate of Lead and Opium Pills, 

$. — Acetate of Lead, twelve to twenty-four grains; Opium, three to 
twelve grains ; mix, and divide into twelve pills. Take one every three 
or four hours. 

In dysentery, 

115. Enema of Laudanum and Starch, 

Prepare half an ounce of Starch, thin enough to be drawn into a small 
syringe ; add from twenty to sixty or more drops of Laudanum, accord- 
ing to the case; mix, and inject into the bowel. 

In severe dysentery, retention of urine, very painful hcemorrhoids, etc. 

116. Enema of Sulphate of Zinc and Laudanum, 

To four fluidounces of Flaxseed Tea, made without boiling, add forty 
drops of Laudanum, and from four to ten grains of Sulphate of Zinc ; 
mix, and inject into the rectum. 

In obstinate chronic dysentery, 

117. Quinine, Ipecac, Camphor, and Opium, 

R. — Quinine, one scruple; Camphor, two scruples ; Ipecacuanha, five 
grains ; Opium, ten grains ; mix, and divide into twenty powders (or 
pills). Take, one every three or four hours. 

In asthenic, malarious dysentery. 

118. Ointment of Galls and Opium, 

!R. — Powder of Galls, two drachms; Opium, ten grains; Lard, one 
ounce ; mix. Apply as ointment. 
For piles, 

119. Spermaceti Ointment and Opium, 

R. — Ointment of Spermaceti, Ointment of Rose Water (Cold Cream) 
or Grlyceramyl, an ounce ; Opium, ten grains ; mix. To be used as 
ointment. 

For piles. 

120. Belladonna Ointment, 

R. — Extract of Belladonna, a drachm ; Spermaceti Ointment, an ounce ; 
mix. Use as ointment. 
For painful piles, 

121. Tannic Acid Wash, 

R. — Tannic Acid, twenty to thirty grains; Water, six fluidounces; 
dissolve. To be injected into the rectum (cooled with ice) for bleeding 
piles. 






FORMULAE. 383 



122. Soda and Sweet Spirits of Nitre. 

R. — Bicarbonate of Soda, three drachms; Sweet Spirit of Nitre, six 
fluidrachms ; Peppermint Water, enough to make six fluidounces ; dis- 
solve. Take a tablespoonful three or four times daily. 

In uric acid gravel. 

123. Benzoic Acid and Soda. 

R. — Bicarbonate of Soda, two drachms ; Phosphate of Soda, half an 
ounce ; Benzoic Acid and Gum Arabic, each two drachms; Sweet Spirit 
of Nitre, half a fluidounce ; Peppermint Water, enough to make six fluid- 
ounces ; mix. Take from a teaspoonful to a tablespoonful, occasionally. 

In gravel. 

124. Opium Suppositories. 

R. — Opium, one or two grains: Cacao (Cocoa) Butter, a sufficient 
quantity ; mix, and introduce into the rectum. 

For painful haemorrhoids, dysmenorrhea, irritation of the bladder, etc. 

125. Belladonna Suppositories. 

R. — Extract of Belladonna, one to four grains ; Cacao Butter, a suffi- 
cient quantity ; mix, and introduce into the bowel. 
For painful haemorrhoids, etc. 

126. Benzoic Acid. 

R. — Benzoic Acid, two drachms ; Cinnamon Water, six fluidounces; 
dissolve. Take a tablespoonful thrice daily. 

In irritation of the bladder, incontinence of urine, etc. 

127. Croton Oil. 

R. — Croton Oil, four drops ; Crumb of Bread or Conserve of Roses, a 
sufficient quantity to make four pills ; mix, and divide. Take one every 
four hours, until they operate. 

As a powerful cathartic, in rare cases. 

128. Lead-water for the Eyelids, 

To a fluidounce of pure River or Spring Water, add one drop of Gou- 
lard's Extract of Subacetate of Lead. Apply this with a cameVs hair 
pencil, to the outside of the lids, frequently. 

129. Alum Eye-water. 

5. — Two to four grains of Alum; Water, one fluidounce; dissolve. 
Drop into the eye from a quill, or a hair pencil, once or twice daily. 

130. Collyrium of Nitrate of Silver. 

^. — Nitrate of Silver, two to four grains ; Distilled Water, one fluid- 
ounce ; dissolve. Apply to the inside of the lids with a hair pencil, or 
drop between the lids. 



384 FORMULAE. 



131. Atropia Solution for the Eye. 

]J. — Sulphate of Atropia, two grains; Water, one fluidounce; dissolve. 
Drop into the eye once or twice daily. 
To dilate the pupil ; as in iritis. 

132. Lotion for the Ear. 

I£. — Glycerin and Warm Water, each half a teaspoonful ; mix. Pour 
into the ear from a teaspoon (in preference to a syringe) twice daily. 
For otalgia, or irritation of the ear. 

133. Olive Oil and Laudanum. 

Mix half a teaspoonful of warm Olive Oil with ten drops of Laudanum ; 
pour it into the ear. 
For earache. 

134. Bromide of Potassium. 

R. — Bromide of Potassium, half an ounce ; Cinnamon Water, six fluid- 
ounces ; dissolve. Take a tablespoonful at night, or thrice daily. 
In hysteria, spermatorrhoea, etc. 

135. Resin of Jalap. 

R. — Resin of Jalap, one scruple; divide into three parts. Give one 
every four hours till they operate. 
An active cathartic. 

136. Podophyllum Pills. 

R. — Resin of Podophyllum, two grains ; Turkey Rhubarb, eight 
grains ; Oil of Anise, two drops ; divide into eight pills. Take one or 
two at once. 

Cathartic and cholagogue. 

137. Strychnia. 

I£. — Strychnia, half a grain ; Conserve of Roses, sixteen grains ; mix, 
and divide into sixteen pills. Take one or two, thrice daily. 
Cautiously, in some cases of paralysis, etc. 

138. Stimulating Liniment. 

]J. — Oil of Turpentine, Spirit of Camphor, Water of Ammonia, and 
Olive Oil, each two tablespoonfuls ; mix well together, for external appli- 
cation. 

In chronic rheumatism, bruises, sprains, etc. 

139. Sassafras Liniment. 

I£. — Oil of Sassafras, two fluidrachms ; Water of Ammonia, a table- 
spoonful ; Camphorated Soap Liniment, three fluidounces ; mix. 
For swellings of joints, etc. 

140. Iodide of Potassium. 

R. — Iodide of Potassium, a drachm ; Cinnamon Water, six fluidounces ; 
dissolve. Take a tablespoonful thrice daily. 
In syphilitic rheumatism, etc. 



FORMULAE. 385 



141. Enema of Castor Oil, Soap, and Molasses, 

Mix together a tablespoonful of Oil, and the same of Molasses, with a 
pint of warm Water, in which a little Castile or good yellow Soap has 
been dissolved. Inject into the rectum with a syringe. 

To empty the bowel promptly. 

142. Phosphate of Iron. 

]J. — Phosphate of Iron, one drachm ; divide into twelve powders. 
Take one thrice daily, in water. 
A good chalybeate tonic. 

143. Assafoetida Pills. 

R. — Assafoetida, one drachm; divide into twenty pills. Take one 
every two or three hours. 
For hysterical nervousness. 

144. Solution of Morphia with Valerian. 

Vf_. — Solution of Sulphate of Morphia, and Fluid Extract of Valerian, 
each one fluidounce ; mix. Take one or two teaspoonfuls as required. 
In delirium tremens. 

145. Pills of Opium, Camphor, and Eyoscyamus. 

R. — Opium, four grains ; Camphor, twelve grains ; Extract of Hyoscya- 
mus, a scruple ; mix, and divide into twelve pills. Take one every three 
or four hours ; or, one or two at night. 
. A good calmative. 

146. Gallic Acid. 

I£. — Gallic Acid, two drachms and a half; Syrup of Cinnamon, four 
fiuidounces ; mix. Take a dessert-spoonful every two, three, or four 
hours. 

An astringent, in hemorrhages, diabetes, etc. 

147. Oil of Turpentine Mixture. 

R. — Oil of Turpentine, two to four fluidrachms ; Compound Spirit of 
Lavender, half a fluidounce ; Laudanum, twenty minims ; Sugar and 
Gum Arabic, each two drachms ; Water, enough to make six fiuidounces ; 
mix. Take a tablespoonful at once. 

In hemorrhages, typhoid fever, etc. 

148. Glyceramyl, 

R. — Mix together two drachms of Starch and two fiuidounces of Bower's 
or Price's Glycerin, cold ; heat gradually to about 240° Fahr., stirring 
all the time ; then let it cool. 

A very soothing local emollient. 

149. Neutral Mixture. 

R. — Citrate of Potassa, two drachms ; Lemon Syrup, half a fluidounce ; 
Water, three and a half fiuidounces ; mix. Dose, a tablespoonful every 
two or three hours, with one of water, in fever. The lemon syrup may 
be omitted without disadvantage. 
33 



386 FORMULA. 



150. Spiritus Minder eri with Nitre. 

R. — Liquor of Acetate of Ammonia, three fluidounces and a half; 
Sweet Spirit of Nitre, half a fluidounee ; mix. Take a tablespoonful 
every two or three hours, with a little water. 

In typhoid fever . 

151. Jalap and Squills. 

R. — Resin of Jalap, half a drachm to a drachm ; Squills, twelve grains 
to a scruple ; mix, and divide into twelve powders. Take one at once. 
As cathartic, in cerebral congestion, hydrocephalus, etc. 

152. Sulphite of Soda. 

R. — Sulphite of Soda, two to four drachms ; Mucilage of Gum Arabic, 
six fluidounces ; mix. Take a tablespoonful every three or four hours. 
In zymotic diseases, as glanders, etc. 

153. Assafcetida and Expectorants. 

R. — Syrup of Ipecac, two fluidrachms and a half; Syrup of Squills, 
three or four fluidrachms ; Mixture of Assafcetida, enough to make two 
fluidounces ; mix. Give one or two teaspoonfuls at once. 

In hooping-cough. 

154. Belladonna Mixture. 

R. — Extract of Belladonna, one grain ; Mucilage of Gum Arabic, two 
fluidounces ; mix. Give one or two teaspoonfuls thrice daily. 
In severe hooping-cough. 

155. Fluid Extract of Hyoscyamus. 

I£. — Fluid Extract of Hyoscyamus, half a fluidrachm ; Orange-flower 
Water, or Camphor Water, four fluidounces ; mix. Give from a tea- 
spoonful to a tablespoonful, every three or four hours. 

In severe hooping-cough. 

156. Chlorate of Potassa. 

R. — Chlorate of Potassa, two drachms and a half; Peppermint Water, 
four fluidounces ; dissolve. Take a tablespoonful every three hours. 
In diphtheria, ulcerated sore mouth, etc. 

157. Chlorate of Potassa and Chloride of Iron. 

fy. — Chlorate of Potassa, two drachms ; Tincture of Chloride of Iron, 
one fluidrachm : Simple Syrup and Peppermint Water, each two fluid- 
ounces ; mix. Take a tablespoonful every three hours. 

In diphtheria. 

158. Creasote in Glycerin. 

Dissolve four to eight drops of Creasote in two fluidounces of Glycerin, 
diluted with an equal bulk of Water. 
Use as gargle. 



formulae. 381 



159. Quinine Pills, 

R. — Divide twenty grains of Sulphate of Quinine into ten or twenty 
pills. Take oue as required. 
For intermittent fever, etc. 

160. Sulphate of Cinchonia Solution, 

I£. — Sulphate of Cinchonia, forty-eight grains ; Aromatic Sulphuric 
Acid (Elixir of Vitriol), a fluidrachrn and a half; Compound Tincture of 
Cardamom, half a fluidounce ; Peppermint Water, enough to make four 
fluidounces. Take a teaspoonful or two as required. 

For intermittent, etc. 

161. Sulphate of Cinchonia Pills, 

R. — Sulphate of Cinchonia, two scruples; divide into twenty pills. 
Take one as required. 
As tonic* or for intermittent, 

162. Quinine and Iron Pills. 

]£. — Sulphate of Quinine, a scruple ; Pill of Carbonate of Iron (Val- 
leix's mass) a drachm ; mix, and divide into twenty pills. Take one 
three or four times daily. 

An admirable tonic, after intermittent, etc. 

163. Capsicum Pills, 

I£. — Powdered Capsicum, a drachm ; divide into twelve pills. Take 
one every hour or two. 

In the chill of pernicious fever , 

164. Calomel, Quinine, Camphor, and Opium. 

R. — Calomel, Quinine, and Camphor, each eight grains ; Opium, two 
grains ; divide into eight pills. Take one every half hour, hour, or two 
hours. 

In pernicious fever. 

165. Nitromuriatic Acid, Nitre, and Camphor Water. 

ty, — Nitromuriatic Acid, half a fluidrachrn ; Sweet Spirit of Nitre, half 
a fluidounce ; Camphor Water, five and a half fluidounces ; dissolve. 
Take a tablespoonful every two or three hours. 

In low fever, 

166. Nitric Acid. 

I£. — Nitric Acid, forty drops ; Water, eight fluidounces ; dissolve. 
Take one or two tablespoonfuls every three hours. 
In typhus fever. 

167. Guaiacum. 

R . — Tincture of Guaiacum, two fluidounces. Take a teaspoonful thrice 
daily, in water. 

For chronic rheumatism. 



388 FORMULJE. 



168. Iodide of Potassium Solution. 

R. — Iodide of Potassium, two drachms ; Peppermint Water, six fluid- 
ounces ; dissolve. Take a tablespoonful thrice daily. 
For syphilitic rheumatism. 

169. Iodide of Mercury. 

R. — Green Iodide (Protiodide) of Mercury, twelve grains ; Conserve 
of Roses, a scruple ; divide into twelve or twenty-four pills. Take one 
twice daily. 

In syphilis. 

170. Donovan's Solution. 

$. — Liquor of the Iodide of Mercury and Arsenic, half a fluidounce. 
Take from three to five drops twice or thrice daily. 
In secondary syphilis, obstinate cutaneous eruptions, etc. 

171. Injection for Gonorrhoea. 

R. — Sulphate of Zinc, four grains ; Water, two fluidounces ; dissolve. 
Use once daily. 

172. Injection for Gonorrhoea. 

R. — Solution of Subacetate of Lead (Goulard's) half a drachm to a 
drachm ; Water, four fluidounces. 
Use once daily, 

173. Injection for Gonorrhoea. 

R. — Chloride of Zinc, two grains ; Glycerin and Water, each a fluid- 
ounce ; dissolve. 
Use once daily. 

174. Copaiba Mixture. 

R. — Copaiba, half a fluidounce ; Compound Spirit of Lavender, two 
fluidrachms ; Sugar and Gum Arabic, each two drachms ; Peppermint 
Water, enough to make six fluidounces. Take a tablespoonful thrice 
daily. 

In gonorrhoea. 

175. Cubebs Mixture. 

]£. — Oil of Cubebs, two drachms ; Sweet Spirit of Nitre, half a fluid- 
ounce ; Sugar and Gum Arabic, each two drachms ; Peppermint Water, 
enough to make six fluidounces ; mix. Take a tablespoonful thrice daily. 

In gonorrhoea. 

176. LugoVs Solution. 

$. — Iodine, six drachms ; Iodide of Potassium, a troyounce and a 
half ; Distilled Water, a pint ; dissolve. Dose, five or six drops, twice 
daily, in water. 

In scrofulous affections. 



FORMULA. 389 

177. Glycerole of Zinc. 

I£. — Oxide of Zinc, half a drachm ; Bower's or Price's Glycerin, four 
fluidounces ; mix. Apply externally, as an emollient. Shake before 
using it. 

178. Cold Cream with Zinc. 

R. — Acetate of Zinc, two grains, dissolved in one fluidrachm of Rose 
Water; mix with one ounce of Ointment of Rose Water (Cold Cream). 
Apply externally, for erythema. 

179. Lead Ointment. 

I£. — Carbonate of Lead, four grains ; Glycerin, a fluidrachm ; Simple 
Cerate, one ounce ; mix. 
For chronic erythema, etc. 

180. Glycerole of Lead. 

Vf.. — Carbonate of Lead, one drachm ; Glycerin, four fluidounces ; mix. 
As a local application, for ophthalmia (to the outside of the lids with a 
hair pencil), inflamed haemorrhoids, periostitis, etc. 

181. Ointment of Oxide of Zinc. 

~fy. — Oxide of Zinc, two drachms ; Lard, one ounce ; mix. Apply 
locally, for eruptions on the face, etc. 

182. Colchicum and Ipecacuanha. 

Tfy. — Wine of Colchicum Root, and Wine of Ipecac, each, two flui- 
drachms ; mix. Take twenty drops, in water, thrice daily. 
In pustular diseases of the shin. 

183. Ointment of Sulphuret of Potassium. 

R. — Sulphuret of Potassium, and Carbonate of Soda, each two drachms) 
Lard, two ounces ; mix. 
For tinea capitis, etc. 

184. Sulphite of Soda and Glycerin. 

R. — Sulphite of Soda, two ounces ; Glycerin, four fluidounces ; Water, 
enough to make a pint ; mix. 

Use as lotion, in chronic diseases of the skin. 

185. Stimulating Embrocation. 

R. — Aromatic Spirit of Ammonia, Spirit of Rosemary, and Glycerin, 
each a fluidounce ; Tincture of Cantharides, three fluidrachms ; Rose- 
water, enough to make eight fluidounces ; mix. 

For the scalp, in premature baldness. 

186. Cantharides and Castor Oil Pomade. 

R. — Balsam of Tolu, two drachms ; Oil of Rosemary, twenty minims ; 
Tincture of Cantharides, two fluidrachms ; Castor Oil, four fluidrachms ; 
Lard, an ounce and a half ; mix. 

For premature baldness. 

33* 



390 FORMULA. 



187. Ointment of White Precipitate. 

I£. — Ammoniated Mercury, one scruple ; Glycerin, a fluidrachin ; Oil of 
Bitter Almonds, three drops ; Lard, or Simple Ointment, an ounce ; mix. 
For acne rosacea, etc. 

188. Iodide of Sulphur Ointment. 

R. — Iodide of Sulphur, one scruple ; Lard, one ounce; mix. 
For army itch, etc. 

189. Astringent Powder. 

ty. — Powder of Krameria, half an ounce ; Prepared Chalk, two drachms ; 
Dry Starch, an ounce and two drachms ; mix. 

To be dusted on the skin in eczema, lichen agrius, etc. 

190. Juniper Tar Soap. 

I£. — Oil of Juniper (Huile de Cade), Soft Soap, and Alcohol, each a 
fluidounce ; mix. 

Apply as local alterative, in obstinate skin diseases. 

191. Anti-pruriginous Lotion. 

R. — Oil of Juniper and Alcohol, each a fluidounce; Water, six fluid- 
ounces ; mix. 

For itching of the skin, in prurigo senilis, etc. 

192. Acid Lotion. 

]J. — Muriatic Acid, twenty drops ; Water, four fluidounces ; dissolve. 
For obstinate itching. 

193. Lotion of Blue Vitriol. 

5. — Sulphate of Copper, six grains ; Elderflower Water, two fluid- 
ounces ; dissolve. 

Use as lotion, for chronic erythema, etc. 

194. Lotion of Corrosive Sublimate. 

fy. — Bichloride of Mercury, four grains ; Alcohol and Distilled Water, 
each a fluidounce ; dissolve. 
In favus, etc., as paraciticide. 

195. Astringent and Sedative Lotion. 

]J. — Creasote, eight drops ; Tincture of Krameria, two fluidrachms ; 
Hydrocyanic Acid, eight drops ; Distilled Water, four fluidounces ; mix. 
In irritative and obstinate skin diseases. 

196. Sedative Lotion. 

I£. — Cyanide of Potassium, fifteen grains ; Water, eight ounces ; dis- 
solve. Apply externally. It should be kept in a dark place. 
For lichen or prurigo. 



FORMULAE. 391 



197. Sulphur o- alkaline Ointment, 

R. — Two drachms of Sulphur ; one drachm of Carbonate of Potassa ; 
and one ounce of Lard ; mix. 
For itch, 

198. Iodide of Potassium and Glycerin, 

fy, — Iodide of Potassium, half an ounce ; Glycerin, two fluidounces ; 
mix. Use as lotion. 

For scabies, army itch, etc. 

199. Iodide of Potassium and Iodide of Sulphur, 

5. — Iodide of Potassium, half an ounce ; Iodide of Sulphur, a drachm ; 
Glycerin and Rose-water, each two fluidounces ; Oil of Bitter Almonds, 
three drops ; mix. 

For itch , etc. 

200. Ointment of Carbonate of Potassa, 

I£. — Carbonate of Potassa, one drachm ; Glycerin, one fluidrachm ; 
Lard, an ounce ; mix. 
For eczema, herpes, etc. 

201. Aloes Pills, 

I£. — Powder of Aloes, one to two scruples ; Oil of Cloves, four drops ; 
mix, and divide into twenty pills. Take one twice or thrice daily. 
For amenorrhea, 

202. Aloes and Iron, 

R. — Aloes, twenty grains ; Quevenne's Metallic Iron (per hydrogen), 
half a drachm ; Oil of Cloves, three drops ; mix, and divide into twenty 
pills. Take one thrice daily. 

For amenorrhea. 

203. Camphor, Lavender, Paregoric, and Ginger, 

R. — Spirits of Camphor, one fluidrachm ; Paregoric, two fluidrachms ; 
Tincture of Ginger, half a fluidrachm ; Compound Spirit of Lavender, 
half a fluidounce ; Water, enough to make two fluidounces ; mix. Take 
a dessert-spoonful every hour or two. 

In dysmenorrhea, 

204. Alum Lotion, 

!£.— Alum, two drachms ; Water, eight fluidounces ; dissolve. Inject 
into the vagina, once or twice daily. 
For leucorrhcea, 

205. Tannin Lotion, 

R. — Tannic Acid, two drachms ; Glycerin, a fluidounce ; Water, seven 
fluidounces; mix. Inject into the vagina daily. 
For leucorrhea, 

206. Santonin, 

R.— Santonin, half a drachm; divide into twelve pills. Take one 
twice daily. 

An excellent vermifuge. For a child, the dose should be reduced. 



392 FORMULAE. 



207. Senna and Pink-Root Infusion. 

R. — Leaves of Senna, and Root of Spigelia, each half an ounce; 
Boiling Water, a pint and a quarter ; infuse, covered, for two hours* 
Take a wineglassful morning and night. 

A good vermifuge. 

208. Fluid Extract of Senna and Spigelia. 

I£. — Fluid Extract of Senna and Spigelia, a dessert-spoonful ; take it 
in the morning, on an empty stomach. 
For worms. 

209. Suppository of Santonin. 

R. — Santonin, twelve grains; Cocoa Butter, a sufficient quantity to 
make four suppositories ; mix, and divide. Introduce one into the bowel 
at bedtime. 

For seat-worms ; an infallible remedy. 

210. Corrosive Sublimate Lotion. 

I£. — Bichloride of Mercury, a scruple ; Water, four fluidounces ; dis- 
solve. Use as wash. 
To destroy lice. 

211. Cocculus Indicus. 

ty. — Seeds of Cocculus Indicus, eighty grains ; Prepared Lard, an 
ounce. Bruise the seeds well in a mortar, and mix with the lard. 
To destroy lice. 

212. Carbolic Acid and Glycerin. 

R. — Carbolic Acid, one or two drachms; Glycerin, a fluidounce ; 
Water, enough to make eight fluidounces ; mix. Use as lotion. 
To destroy lice, or relieve pruritus. 



MISCELLANEOUS PRESCRIPTIONS. 

213. Syrup of Iron, Quinine, Strychnia. 

]£. — Ferri Sulphatis, 5 V ; Sodae Phosphatis, gvj — §j ; Quiniae Sul- 
phatis, gr. cxcij ; Acidi Sulphurici Diluti, quantum sufficit ; Aquae Am- 
moniae, quantum sufficit ; Strychniae, gr. vj ; Acidi Phosphorici Diluti, 
fgxiv ; Sacchari Albi, ^xiv. Dissolve the sulphate of iron in one ounce 
of boiling water, and the phosphate of soda in two ounces of boiling 
water. Mix the solutions, and wash the precipitated phosphate of iron 
until the washings are tasteless. With sufficient diluted sulphuric acid, 
dissolve the sulphate of quinia in two ounces of water. Precipitate the 
quinia with ammonia water, and carefully wash it. Dissolve the phos- 
phate of iron and the quinia thus obtained, and also the strychnia, in 
the diluted phosphoric acid. Then add the sugar, dissolve the whole, 
and mix without heat. 

Dose, a teaspoonful thrice daily, in anaemia, chlorosis, leucocythozmia, 
&c. This is a favorite prescription with Dr. Aitken. 






FORMULA 393 



214. Chlorodyne. 

R. — Chloroformi, fgss ; iEtheris sulphurici, TT\,xc ; Olei Menthae Piperi- 
tae, gtt. viij ; Resinae Cannabis Indicae, gr. vj ; Capsici, gr. ij. Mix, 
shake occasionally, and allow it to stand for a few days. Also, Morphiae 
Muriatis, gr. xvj ; dissolved by the aid of heat in f5ij of Water ; to 
which, when cold, add of Scheele's Hydrocyanic Acid, n^lxv ; Perchloric 
Acid, f^j ; of Simple Syrup (or treacle), fgij. Add this gradually to 
the first mixture, and add enough water to make four fluidounces in all. 
Dose, thirty minims. 

A powerful narcotic, whose pretensions, however, have been exaggerated, 

215. Dr. Hammond' 's Alterative for Syphilis, 

]J. — Potassii Iodidi, £j ; Hydrargyri Bichloridi, gr. vj ; Aquae, f^xij ; 
misce. 

Take a teaspoonful thrice daily. 
In syphilitic rupia etc. 

216. Cinchonated Syrup of Iron. 

R. — Ferri Phosphatis, £j ; 

Aquae, f§jss ; solve. 

Cinchoniae Sulphatis, Qj ; 

Acidi Sulphurici Diluti, gtt. xx ; 

Aquae, f^jss ; solve. 
Misce, et adde Syrupi Aurantii quantum sufficit ut fiat mistura, fgiv. 
Dose, a dessert-spoonful, as a tonic. 

217. Antidote for Arsenic. 

R. — Liquoris Ferri Tersulphatis (U. S. P.), et 
Aquae Ammoniae, aa fljiv ; 
Aquae, Oj ; misce. 
Pour this mixture into a small muslin bag, strain and wash it ; then 
dilute the precipitate with half a pint of water. Give a tablespoonful 
every five minutes. 

218. Compound Rhubarb Pills (U. S. P.). 

R- — Pulveris Radicis Rhei, gr. xxiv ; Aloes, gr. xviij ; Myrrhae, gr. 
xij ; Olei Menthae Piperitae, ui ij ; Aquae, q. s. ; misce bene, et divide in 
pil. no. xij. 

A good, moderately active cathartic. 

219. Compound Cathartic Pills (U. S. P.). 

$• — Extracti Colocynthidis Compositi, gr. xvj ; Extracti Jalapae 
(pulv.), et Hydra^rgyri Chloridi Mitis, aa gr. xij ; Gambogiae, gr. ijss ; 
Aquae, q. s. ; misce, et, divide in pil. no. xij. 

A decidedly active cholagogue cathartic. 

220. Effervescing Solution of Citrate of Magnesia (U. S. P.). 

R.— Magnesiae Carbonatis, gv ; Acidi Citrici, 5viiss ; Syrupi Limonis 
(vel Syrupi Acidi Citrici), fjij ; Aquae, q. s. Dissolve the citric acid in 
four fluidounces of water, and add four drachms of the carbonate of 



394 FORMULAE. 



magnesia, previously rubbed with three fluidounces of water. When 
the reaction has ceased, filter into a strong glass bottle holding twelve 
fluidounces ; into which the syrup has been introduced. Rub the re- 
maining carbonate of magnesia with two fluidounces of water, pour into 
the bottle, cork quickly, and secure the cork with twine. Dose, from 
half a tumblerful to a whole bottle. 

This is the least disagreeable of all cathartic medicines. 

221. Hope's Mixture. 

R. — Aquae Camphorae, fgiv ; Acidi Nitrosi, n\ xxx ; Tincturae Opii, 
W[ xx ; misce. 

Dose, a tablespoonful, every two or three hours. 
In diarrhoza and asthenic dysentery. 

222. Quinine and Chloride of Iron. 

ft. — Quiniae Sulphatis, 9j ; Tincturae Ferri Chloridi, f^ijss. Fiat 
solutio. 

Dose, fifteen drops, in solution. 

In diphtheria, asthenic erysipelas, etc. 

223. Quinine for Children. 

R. — Quiniae Sulphatis, gss ; Pulveris Ghimmi Acaciae, £ss ; Syrupi 
Zingiberis, f^iv ; misce. 

Dose, a teaspoonful (one grain of quinine) or less, as required, in inter- 
mittent, etc. 

224. Effervescing Fever Powders. 

ft. — Acidi Citrici, 5 V -; divide in parts xij. Wrap each of these in a 
white paper. 

ft. — Potassae Bicarbonatis, 5 v J s s ; divide in parts xij. Wrap each of 
these in blue paper. 

For use, dissolve the acid powder in four tablespoonfuls of cold water 
in a tumbler, and add, with stirring, the other powder. One dose every 
two or three hours will be suitable in inflammatory or remittent fever, etc. 

225. Liquid Substitute for Dover' s Powders. 

ft. — Vini Ipecacuanhse, rr\xvj ; Tincturae Opii, tt\xiij ; Spiritus 
JEtheris Nitrici, f5j ; misce. To be taken with water, at bedtime. 
For influenza, etc. 

226. Soda Powders. 

ft. — Soda Bicarbonatis, gr. xxiij. 

ft. — Acidi Tartarici, gr. xx. 
Dissolve each in four tablespoonfuls of water, separately ; then pour 
the solutions together, and drink while effervescing. Ginger syrup may 
be added if desirable. 

227. Scudamore's Gout Mixture, Modified. 

R. — Magnesiae Sulphatis, §j ; Magnesiae Optimae, gij ; Vini Colchici 
Radicis, fgj ; Aquae Menthae Piperitae, f§x. Misce. 
Dose, a tablespoonful every hour until it operates. 



FORMULA. 395 



228. Black Wash. 

R.— Hydrargyri Chloridi Mitis, £j ; Liquoris Calcis, fgiv ; misce. 
Apply on lint. 

A popular lotion for chancre. 

229. Yellow Wash. 

ty. — Hydrargyri Chloridi Corrosivi, gr. xvj ; Liquoris Calcis, f§viij ; 
misce. Apply on lint. 
For chancre. 

230. Volatile Liniment. 

I£. — Aquae Ammoniae et Olei Olivae, aa fgss. Misce. 
To bathe an inflamed throat, etc. 

231. Iodine Ointment. 

I£. — Iodinii, Qj ; Potassii Iodidi, gr. iv ; Aquae, TT\, vj ; Adipis, §j» 
Misce. 

For tumors, chronic inflammation of joints, etc. 

232. Tar Ointment. 

R. — Picis Liquidae, et Sevi (vel Adipis) gij. Mix with the aid of heat, 
and strain through muslin. 
For tinea capitis, etc. 

233. Glycerin Ointment. 

R. — Cetacei, §ss ; Cerae Albae, £j ; Olei Amygdalae Dulcis, 13 ij ; Gly- 
cerinae, f§j. 

Melt the wax and spermaceti with the oil of almonds at a moderate 
heat ; put these into a mortar, add the glycerin and triturate until cold. 

For chapped hands, etc. 

234. Calomel and Camphor Ointment. 

R. — Hydrargyri Chloridi Mitis, gr. viij ; Camphorae, Qj ; Glycerinae, 
f3j ; Cetacei, gss ; Adipis, ^jss. Misce. 
For lichen or herpes of the face, etc. 

235. Sulphur Ointment. 

R. — Sulphuris, §j ; Adipis, §ij ; misce. 
For itch, etc. 

236. Lozenges for Hoarseness. 

]J. — Pulveris Cubebae, §ss ; Ammoniae Muriatis, §j ; Olei Sassafras, 
f£j ; Pulveris Glycyrrhizae, Sacchari Albi, et Gummi Acaciae, aa giij ; 
Syrupi Tolutani, q. s. 

Rub the powders thoroughly together, then add the oil, lastly the 
syrup. Divide the mass into lozenges of ten grains each. 

237. Liquorice and Opium Lozenges (U. S. P.). 

I£. — Opii Pulveris, §ss ; Glycyrrhizae, Gummi Acaciae, et Sacchari 
Albi, aa gx; Olei Anisi, f3j. Rub the powders thoroughly together, 



396 FORMULA. 

then add the oil of anise, and lastly add enough water to form a mass. 
Divide into lozenges, each of ten grains. 

Like " Wistar's Cough Lozenges," these are very soothing to cough, 
when taken at night. 

238. Rhubarb, Magnesia, and Charcoal, 

Take of Powder of Rhubarb Root, Husband's Magnesia, and Prepared 
Charcoal Powder, each a teaspoonful ; Powdered Ginger, half a teaspoon- 
ful ; mix, and divide into three parts. Take one on rising in the 
morning. 

For " biliousness" etc. 

239. Iodide of Lead Ointment. 

I£. — Plumbi Iodidi, 5j 5 Adipis, §j ; misce. 
For scrofulous and other tumors. 

240. Stevens' Saline Draught. 

R. — Sodii Chloridi, $iv; Potassse Chloratis, gr. xxviij ; Sodse Carbon - 
atis, 5ij ; Aquae, fgvj ; dissolve. Take two or three tablespoonfuls every 
half hour, as the " saline treatment" of cholera. 

241. Radcliffe's Phosphorus Pills. 

Take of Phosphorus, six grains ; Suet, six hundred grains. Melt the 
suet in a stoppered bottle capable of holding twice the quantity indi- 
cated. Put in the phosphorus, and, when liquid, agitate the mixture 
until it becomes solid. Roll into three-grain pills, and cover with gelatin. 
Each pill will contain one thirty- third of a grain of phosphorus. 

242. Trousseau's Syrup of Lime. 

Saturate Simple Syrup with unslaked Lime. Or, mix two ounces of 
Lime and eight ounces of Sugar in a mortar, and pour over them a pint 
of boiling water. Take half a teaspoonful two or three times daily, in 
milk. 

For rheumatism. 

243. To make a Sponge-Tent. 

Cut a small elongated and conical piece of sponge, dip it in water, and 
bind it tightly, with fine strong twine or cord, around a central wire ; 
then dry it, remove the cord, coat it with a mixture of equal parts of 
wax, lard, and glycerin, and fasten a piece of tape four inches long to 
the larger end. 

For uterine dilatation, etc. Great care is necessary in its use. 

The dried stem of the sea-tangle (laminaria digitata) is preferred for 
the same purpose by some practitioners. 



ALIMENTS. 39T 

ALIMENTARY PREPARATIONS. 

Barley Water. 

Take of pearl barley, two ounces ; boiling water, two quarts. Before 
adding the water let the barley be well washed. Then boil to one half, 
and strain the liquor. A little lemon-juice and sugar may be added, if 
desirable. 

Rice Water. 

Take of rice, two ounces ; water, two quarts. Boil it for an hour and 
a half, and then add sugar and nutmeg to taste. Some prefer salt. 
An excellent drink in diarrhoea, dysentery, etc. 

Toast Water. 

Cut a slice of stale bread half an inch thick, and toast it brown, with- 
out scorching. Pour over it a pint of boiling water ; cover closely till it 
cools ; then pour off and strain it. 

Oat-Meal Gruel. 

Boil a pint of water in a saucepan ; when boiling, mix with it two 
tablespoonfuls of oat meal, half a pint of milk, and a little salt. Let it 
then simmer for half an hour ; strain it through a hair-sieve, sweeten, 
and add a little nutmeg. A few raisins may be added before the 
boiling. 

Vegetable Soup. 

Put two potatoes, one onion, and a piece of bread, into a quart of 
water ; boil it down to a pint. Then throw in a little chopped celery 
or parsley, and salt. Cover, remove from the fire, and allow it to cool. 

Bread and Butter Broth. 

Spread a slice of well-baked bread with good fresh butter ; sprinkle 
it moderately with salt and black pepper. Pour a pint of boiling water 
over it, cover, and let it stand to cool. 

Lime-water and Milk. 

Take of clear saturated lime-water, and fresh milk, each a wineglass- 
ful ; mix. Let a tablespoonful, or less, be taken at once. This will 
sometimes remain upon an irritable stomach which will retain nothing 
else. 

Chicken Broth. 

Clean half a chicken ; pour on it a quart of cold water, and salt to 
taste ; add a tablespoonful of rice, and boil slowly for two hours ; skim 
well, and add a little parsley. 

Panada. 

Cut two slices of stale bread, without crust ; toast them brown, cut 
them up into squares of about two inches, lay them in a bowl and 
sprinkle with salt and a little nutmeg. Pour on a pint of boiling water, 
and stand to cool. 
34 



398 ALIMENTS, 



Arrow-Root, 

Mix a tablespoonful, or a tablespoonful and a half, with a little cold 
water, till it makes a paste. Boil a pint of water, stir in the arrow-root, 
and boil it a few minutes. Sweeten with white sugar. Brandy or wine 
may be added if necessary ; and half or all milk may be used instead 
of water. A little lemon or orange-peel added before boiling will im- 
prove the flavor. 

Tapioca. 

Cover two tablespoon fuls of tapioca with a teacupful or more of cold 
water, and soak for two or three hours, or over night. Put it then into 
a pint of boiling water, and boil it until it is clear and of the desired 
consistence. Sugar, nutmeg, or wine, etc., may be added as required. 

Sago Jelly, 

Mix well together four tablespoonfuls of sago, the juice and rind of 
one lemon, and a quart of water. Sweeten to taste, let it stand half an 
hour, and boil it, stirring constantly, until clear. Then add a wineglass- 
ful of wine ; currant wine will do. 

Beef-Tea, 

Chop a pound of lean beef into very small pieces, pour over it a pint 
of cold water, cover, and let it stand two hours by the side of the fire. 
Then put it on the fire and boil it for half an hour. Remove the scum, 
skim off all the oil drops, and salt to taste. Do not filter or strain it. 
Good beef-tea should have a rich brown appearance when stirred. 

Essence of Beef, 

Cut up a pound of lean beef into small pieces ; put it into a pint 
bottle, without water, cork it loosely, and immerse the bottle to its neck 
in cold water in a stewpan. Bring the water to a boil, and let it boil 
for two hours. Then pour off the essence. 

Biebifs Broth, 

Chop half a pound of beef, mix it well with one drachm of table salt, 
four drops (ten would be better) of muriatic acid, and eighteen ounces 
of distilled water. Macerate for an hour, and strain through a fine hair 
sieve. Dose, a teacupful. This contains the soluble constituents of the 
meat ; but not all its nutritive elements. 

Biebifs Food for Infants, 

Mix together half an ounce of wheat flour, the same of malt flour, 
seven and a quarter grains of bicarbonate of potassa, and an ounce of 
water. Add five ounces of fresh milk, and put the whole upon a gentle 
fire. When it begins to thicken, take it from the fire, stir it for five 
minutes, heat and stir again until it becomes quite fluid ; finally boil it 
for a short time. Filter it through a sieve to separate the bran ; it is 
then ready for use. It will keep for twenty-four hours. Its effect is 
slightly aperient. 



ALIMENTS. 399 



Complin's Bran Loaf, for Diabetes. 

Take two or three quarts of wheat bran, boil it in two successive 
waters for ten minutes, each time straining it through a sieve, then 
wash it well with cold water (on the sieve), until the water runs off 
perfectly clear ; squeeze the bran in a cloth as dry as you can, then 
spread it thinly on a dish, and place it in a slow oven. — If put in at 
night let it remain until the morning, when, if perfectly dry and crisp, 
it will be fit for grinding. The bran thus prepared must be ground in 
a fine mill, and sifted through a wire sieve of sufficient fineness to require 
the use of a brush to pass it through : that which does not pass at first 
ought to be ground and sifted again, until the whole is soft and fine. 

Take of this bran-powder three troyounces ; three fresh esss ; an ounce 
and a half of butter, and rather less than half a pint of milk. Mix the 
eggs with part of the milk, and warm the butter with the other portion ; 
then stir the whole well together, adding a little nutmeg and ginger, or 
other spice. Just before putting into the oven, stir in, first, thirty-five 
grains of bicarbonate of soda, and then three drachms of dilute hydro- 
chloric acid. Bake the loaf in a basin (well buttered) for an hour or 
rather more. 

Wine Whey. 

Boil half a pint of milk, and, while boiling, add a wineglassful of Ma- 
deira or Sherry wine. Separate the curd, by straining through muslin 
or a sieve. Sweeten the whey to taste, and grate upon it a little nutmeg. 

Egg and Wine, or Brandy. 

Beat up a raw fresh egg, and stir with it two tablespoonfuls of wine, or 
one of brandy. Sweeten or not, according to taste. 

Caudle. 

Beat up a raw egg with a wineglassful of Sherry, and add to it half a 
pint of hot gruel. Flavor with lemon-peel, nutmeg, and sugar. 

Milk Punch. 

Into a tumblerful of milk put one or two tablespoonfuls of brandy, 
whisky, or Jamaica rum. Sweeten well, and grate nutmeg on top. 

Ferruginous Chocolate. 

Mix sixteen ounces of chocolate with half an ounce of carbonate of 
iron. Divide the mass into cakes of one ounce each. One may be dis- 
solved in half a pint of hot milk, to be taken night and morning. 



400 DISINFECTANTS. 



DISINFECTANTS. 



The best preventives of infection are ventilation and cleanliness. 
No agencies can be made to take the place of these. The following are 
the most available temporary aids in purification of insalubrious places. 

For disinfection of privies: sulphate of iron, a pound dissolved in a 
gallon of water ; or the same amount of chloride of lime may be 
thoroughly mixed in water. 

Burnet's Liquid consists of solution of chloride of zinc, twenty-five 
grains in each fluidrachm of water. Of this a pint may be put into a 
gallon of water for use. 

For -water closets, bed-pans, etc., Labarraque's solution of chlo- 
rinated soda may be employed, — a fluidounce to a quart of water; or 
permanganate of potassa, from one to five grains to the ounce of water ; 
or carbolic acid, twenty grains to the pint or quart. This last disinfec- 
tant, much valued in England, is not yet made cheaply here. Coal tar 
possesses its virtues in a dilute form. 

Articles of clothing, contaminated by discharges, etc., from pa- 
tients, if very bad, should be burned. Otherwise, they should be boiled 
thoroughly ; or, at least, plunged into boiling water. Woollens, and all 
clothing which cannot be washed, as well as bedding, should be exposed 
for several hours to a dry heat of from 200° to 250° Fahrenheit. 

Occupied rooms and houses may be disinfected (besides ventila- 
tion) by diffusing in spray through the air Ledoyen's liquid (solution of 
nitrate of lead, made by dissolving one pound of litharge in seven ounces 
of nitric acid and two gallons of water) . Or, by placing in shallow vessels 
the solid chloride of lime (bleaching salt). Fresh whitewashing is bene- 
ficial to the air of a cellar. Charcoal and quicklime are absorbent (espe- 
cially the former) of gases, and thus aid in purifying the air. 

Hospital wards may be disinfected (besides ventilation and cleans- 
ing) by Ledoyen's liquid, or chloride of lime, or bromine left exposed to 
the air in shallow vessels, or iodine, heated moderately. 

Heaps of filth, solid or semi-liquid, may be covered with charcoal, 
two or three inches deep, or with dry earth. Drains, ditches, and 
sewers may be disinfected with sulphate of iron, coal tar, chloride of 
lime, &c. A pound of good chloride of lime will suffice for a thousand 
gallons of running sewage. 

On the subject of ozone as a disinfectant, I refer to works on chemistry 
and hygiene. 



IXDEX OF FORMULA. 



Amenorrhea, F. 201, 202. Gout, F. 37, 45, 47, 48, 49, 227. 

Anaemia, F. 21, 23, 30, 31, 32, 33, 56, Gravel. F. 122, 123, 124, 125, 126. 

71, 142. 
Angina pectoris. F. 47, 48, 49. Hseruatemesis. F. SO. 81. 

Asthma, F. 18, 19, 20, 98, 153. Hemorrhages. F. 146, 147. 

Hoarseness, F 5. 13, 14. 236. 
Baldness, premature. F. 185. 186. Hooping-cough, P. 19, 20. 98, 153, 154, 

Biliousness, F. 218. 219, 220. 226, 238. 155. 
Brain, congestion or inflammation of. Hypertrophy of the heart, F. 41, 42, 

F. 151, 218, 220. 44. 44. 

Bronchitis. F. 1, 4, 13, 14, 15, 16, 17, Hysteria, 22, 23, 142, 143. 
20, 236, 237. 

Influenza. F. 2. 13, 14, 15, 225. 
Insomnia. F. 22 ; 143. 144. 145. 
Intermittent fever, F. 2, 159. 160, 161, 
162, 223. 



Jaundice, F. 21, 218, 219. 



Chlorosis. F. 213. 

Cholera, F. 91, 92, 240, p. 314. note. 

Cholera infantum, F. 107, 108. 109, 

110. 
Cholera morbus. F. 99 (see Vomiting). 
Chorea. F. 22. 23, 32. 33. 34. 
Colic. F. 74. 78, 79, B6, 87, 89, 90. 91, Laryngitis, F. 1, 4, 5. 

93, 94, 96, 100. Leucocythaemia, F. 213. 

Constipation. F. 75. 76, 77, 82, 83, 84. Leucorrhcea, F. 204. 205. 

85, 95. 141. 218. 
Croup, F. 5, 24, 25, 26. 



Lice, F. 210, 211, 212. 

Neuralgia, F. 27, 23, 29, 162, 213, 222. 



Delirium tremens, F. 144. 145. 

Diarrhoea. F. 101, 102, 103, 104, 105, Ophthalmia, F. 88, 123, 129, 130, 131. 

106, 110, 221. 
Diphtheria, F. 54, 55, 56, 156, 157. 158, Palpitation. F. 66, 72. 90, 216, 226. 

Paralysis, F. 34, 137, 138, 139. 
Pericarditis, endocarditis, F. 4. 6, 7, 8, 

9, 10. 
Periostitis, F. 88. 
Peritonitis, F. 6, 7, 8. 9. Ill, 113. 
Pernicious fever, F. 163. 164. 
Phthisis, F. 30, 31. 32. 33. 35. 36. 
Piles. F. 83, 118, 119, 120, 121, 124, 

125. 
Pleurisv. F. 1. 4, 6, 7. 8, 9, 10. 11. 
Pleurodynia, F. 27, 28, 29, 138, 139. 
Pneumonia, active, F. 1, 4, 6, 7. 

asthenic, F. 2, 3, 7, 8. 
Pyaemia, F. 2, 3, 152. 



222. 
Dropsy, F. 8, 10, 11, 12. 38, 39, 40. 

Dvsenterv, F. 97. Ill, 112, 113, 114, 

115, 116, 117, 221. 
Dvsinenorrhcea, F. 124. 125, 203. 
Dyspepsia, F. 34, 71, 72, 73, 74, 226. 

Ear-ache, F. 133. 
Erysipelas, F. 5, 184. 

Fever, F. 7, 149, 150, 165, 166, 224. 



Gangrene of lung, F. 2, 3. 152. 

Gastritis, chronic, F. 62. 63, 64. 

Glanders, F. 152. 

Gonorrhoea, F. 171, 172, 173, 174, 175. Remittent fever, F. 2, 7 ; 224. 

34* 



402 



INDEX — FORMULAE. 



Rheumatism, F. 37, 45, 46, 61, 138, 
139, 140, 167, 231, 242. 

Scarlet fever, F. 7, 26, 149, 150, 151, 
224 

Scrofula, F. 30, 31, 32, 33, 176. 

Sick headache, F. 66, 74. 

Skin, diseases of, F. 148, 177, 178, 179, 
180, 181, 182, 183, 184, 187, 188, 
189, 190, 191, 192, 193, 194, 195, 
196, 197, 198, 199, 200, 232, 233, 
234, 235. 

Sore, mouth, F. 50, 51, 52, 53, 54, 57 
58, 59. 

Spermatorrhoea, F. 22, 30, 33, 162. 

Spitting of blood, F. 80, 81, 146, 147. 



Sprains, F. 138, 139. 
Syphilis, F. 168, 169, 170, 215, 228, 
229. 

Tonsillitis, F. 5, 60, 230. 

Tumors, F. 231, 239. 

Typhlitis, F. 87. 

Typhoid fever, F. 2, 7, 147, 150, 165. 

Ulcer of stomach, 62, 63, 64, 80, 81. 

Vomiting, F. 63, 64, 65, 66, 67, 68, 69, 
70. 

Worms, F. 206, 207, 208, 209. 



GENERAL INDEX. 





PAGE 


PAGE 


Abdominal diseases, physical diag 




Alimentary preparations, 


397 


nosis of, 


77 


Alison, 


22 


dropsy, 


247 


houses of refuge from cho- 




Ablutions in fever, 


93 


lera, 


315 


Abseess of the brain, 


213 


on quarantine, 


307 


liver, 


187 


Alkalies in gout and rheumatism, 


102 


lung, 


127 


Alkalinity of urine, 


56 


retropharyngeal, 


160 


Aloes and iron, F. 202, 


391 


Acetate of ammonia, F. 7, 


369 


pills, F. 201, 


391 


lead and opium pills, F. 114, 


382 


rhubarb and belladonna, F. 




lead pills, F. 41, 


373 


85, 


378 


potassa, F. 8, 


370 


Alopecia, 


344 


Acid lotion, F. 192, 


390 


Alphos, 


342 


Acidity of perspiration, 


62 


Alterative remedies, 


83 


urine, 


56 


treatment, 


105 


Acinesia, 


63 


Alum, brandy, and water, F. 59, 


375 


Acne, 


346 


eye-water, F. 129, 


3S3 


Aconite, 


90 


lotion, F. 204, 


391 


embrocation, F. 27, 


372 


Amblyopia, 


64 


Acton, treatment of spermator- 




Amenorrhoea, 61 


355 


rhoea, 


359 


Ammonia mixture, F. 3, 


369 


Acute phthisis, 


142 


rhubarb, and paregoric, F. 




softening of stomach, 


162 


109, 


381 


yellow atrophy of liver, 


190 


soda, and morphia, F. 67, 


376 


Addison's disease, 


335 


Ammoniated urine, 


57 


iEgophouy, 7 


3, 74 


Ammonio-ferric alum, F. 80, 


37S 


Affections of alimentary system, 


156 


Amphoric sounds, 68, 70, 7< 


I 74 


brain and nervous system, 


209 


Amyloid liver, 


193 


heart and aorta, 


147 


Analeptic treatment, 94, 95, 97 


kidneys and bladder, 


196 


Analysis of urine, 


60 


liver, 


186 


Anaemia, 29, 


329 


respiratory system, 


121 


death by, 


46 


skin, 


337 


Anaesthesia, 4i 


>, 63 


spleen, 


195 


Anaesthetics, 


112 


Ague, 


266 


Anderson, McCall, on parasitic 




cake, 


196 


vegetations, 


351 


Aitken, definition of tuberculosis, 


326 


Aneurism of aorta, 


76 


recipe for cholera, 


314 


thoracic, 


155 


syrup of phosphates. &c, 


329 


abdominal, 


156 


Air, impure, promotive of phthisis 


143 


Angeioleucitis, 


333 


Alarm, at night, in children, 


221 


Angina pectoris, 


153 


Albuminuria, 58, 


197 


Animism, 


16 


Alcohol in phthisis, 


144 


Anodyne remedies, 


83 


in treatment of debility, 


98 


Anorexia, 


48 



404 



INDEX. 



PAGE 

Anstie on contagion of typhoid 

fever, 293 

on stimulation, 99 

Anthrax, 335 

Antidote for arsenic, F. 217, 393 

Antidotal treatment, 83, 100 

Anti-emetics, 162, 163 

Antilithics, 100, 101 

Antiphlogistic treatment, 85 

Antipruriginous lotion, F. 191, 390 
Antipsorics, 101 

Anti-scorbutics, 101 

Antisyphilitic treatment, 101 

Anus, fissure of, 185 

prolapsus of, 186 

Anxiety, expression of, in disease, 65 
Aerta, aneurism of, 155, 156 

Aphasia, 134 

Aphonia, 133 

Aphthse, 157 

Apnoea, death by, 47 

Apoplectic syncope, 152 

Apoplexy, ' 222, 244 

Apparatus for examination of urine, 60 
Appetite in disease, 48 

Arachnitis, 209 

spinal, 214 

Arcus senilis, 63 

Aretaeus, 14, 18 

Army itch, 351 

Aromatics, &c, for colic, F. 89, 379 
Arrow-root, 397 

Arthritis, 318 

rheumatoid, 317 

Ataxiae, 119 

Ataxie locomotrice progressive, 229 
Atelectasis pulmonum, 128 

Atomization, 111 

Atrophy, 34 

of liver, acute yellow, 190 

Atropia solution for the eye, F. 131, 384 
Ayre's treatment of cholera, 310 

Auscultation, 66, 70 

Autopsic inspection, 80, 81 

Ascarides, 363 

Ascites, 247 

Asclepiades, 15 

Asphyxia, 367 

Assafcetida and expectorants, F. 

153, 386 

mixture, F. 98, 380 

pills, F. 143, 385 

Asthenia, death by, 46 

Asthma, 130 

Astringent and sedative lotion, F. 

195, 390 

Astringent powder, F. 189, 390 

Babington, the first laryngoscope, 77 



Bacon, 

Balancive remedies, 

Baldness, 

Barley water, 

Barthez, 

Bartholow on spermatorrhoea, 

Beale, 

Beef essence, 



PAGE 

15 

83, 84 
344 
397 
16 
358 
19 
398 

Beef-tea, 144, 398 

Bell, C. W., view of cholera, 304 

Belladonna, as a preventive of 

scarlet fever, 256 

mixture, F. 154, 386 

ointment, F. 120, 382 

suppositories, F. 125, 383 

Bennet, H., on hysterotomy, 356 

Bennett, J. H., 19, 23 

on exudation, 86 

on leucocythsemia, 331 

treatment of inflammation, 87 
on typhus and typhoid fevers, 289 
Benzoic acid, F. 126, 383 

and soda, F. 123, 383 

Bergson's steam-inhaler, 112 

Beri-beri, 330 

Bernard, experiments of, 84 

on liver-sugar, 203 

Bibron's antidote, 367 

Bichat, 16 

Biermer, lime-water in diphthe- 
ria, 113 
Bigelow, 17, 22 
Bilharzia, 362 
Bile in urine, tests for, 56 
Bilious dysentery, 182 
fever, 270 
Bites of serpents, 367 
Bitters in debility, 97 
Black vomit, 281 
wash, F. 228, 395 
Bladder, inflammation of, 207 
Bleeding from the nose, 243 
Blood in disease, 50, 51 
Blood-corpuscles in urine, 57 
Blood-letting, 85 
authorities upon, 87 
Blood, spitting of, 243 
vomiting of, 245 
Blowing respiration, 73 
Blue mass and ipecac, F. Ill, 381 
ipecac, and camphor, F. 
112, 381 
vitriol lotion, F. 193, 390 
Boerhaave, 16 
Bohm, desquamation in cholera, 299 
Borax, myrrh, Ac, F. 52, 375 
Borelli, * 15, 18 
Bbttger's test for sugar, 59 
Bouchardat's bread for diabetics, 204 



INDEX. 



405 



PAGE 

Bouchut, on the ophthalmoscope 

in diagnosis, 218 

Boudault's pepsin, 166 

Bowditch, paracentesis, 127 

Bowels, hemorrhage from, 52 

inflammation of, 168 

obstruction of, 175 
Bowring, Sir John, on losses from 

quarantine, 307 
Boyers operation for fissure of 

anus, 185 
Brain, abscess of, 213 
affections of, 209 
inflammation of, 209 
softening of, 213 
Bran loaf, Camplin's, 398 
Bread and butter broth, 397 
Break-bone fever, 265 
Breath, temperature of, 53 
Bretonneau, on diphtheria, 260 
Brigham, on deaths from cholera, 303 
Bright's disease, 197 
Brodie, on fissure of anus, opera- 
tion for, 185 
on prognosis in infantile pa- 
ralysis, 230 
solution of calculus, 201 
Bromide of potassium, F. 22, 

134, 371, 384 
Bronchial dilatation, 132 
sounds, 70, 71 
Bronchitis, 129 
Bronchocele, 336 
Bronchophony, 72, 74 
Broussais, 16 
Brown, 16 
Brown, Baker, clitoridectomy, 232, 359 
Brown- Sequard, bromide of potas- 
sium in epilepsy, 231 
vivisections of, 84 
Bruit de pot fele, 68, 70, 140 
Bucnemia tropica, 345 
Bulging of the chest, 67 
Bulimia, 48 
Bullae, 341 
Burns and scalds, 354 

Cachexia, 30, 118 

Calomel powders, F. 69, 376 

and camphor ointment, F. 234, 395 

and nitre, F. 25, 372 

ipecac, and nitre, F. 6, 369 

and opium pills, F. 86, 378 

opium, and tartar emetic, F. 9, 370 
quinine, camphor, and opium, 

F. 164, 387 

soda, and ginger, F. 107, 381 

Calculus, 60, 200 

Calmative remedies, 83 



PAGE 

Camman's double stethoscope, 70 
Camp fever, 287 
Camphor mixture, F. 103, 380 
ipecac, and opium, F. 113, 382 
lavender, paregoric, and gin- 
ger, F. 203, 391 
Camplin : s bran loaf, 398 
Cancer, 43, 44 
of kidney, 205 
of liver, 194 
of stomach, 164 
Cancrum oris, 158 
Cantharides and castor oil pomade, 

F. 186, 389 

Capillary circulation in disease, 50 
Capsule of G-lisson, inflammation of, 191 

Capsicum pills, F. 163, 387 
Carbolic acid and glycerin, F. 212, 392 

Carbonate of ammonia in urine, 57 

of potassa and nitre, F. 37, 373 

ointment, F. 200, 391 

Carbuncle, 335 
Cardamom and potassa mixture, F. 

66, 376 
Cardiac exhaustion, 154 
Cardialgia, 166 
Carminative mixture, F. 78, 377 
anodyne, F. 90, 379 
for infants, F. 94, 379 
Castor oil and laudanum, F. 97, 380 
and spiced syrup of rhu- 
barb, F. 96, 379 
Catalepsy, 232 
Catalysis in disease, 28 
Catarrh, epidemic, 264 
Catarrhal croup, 136 
Catechu and paregoric, F. 105, 381 
Cavernous respiration, 71, 74 
Cellular pathology, 37 
Celsus, 15 
Cephalalgia, 64 
Cerate of carbonate of lead, F. 88, 379 
Cerebritis, 209 
Cerebro-spinal fever, 284 
meningitis, 284 
Chalk mixture, F. 102, 3S0 
Chapman, John, system of, 17 
neuropathy, 84 
treatment of cholera, 311 
Chapman, N., pathology of, 17 
on phthisis, 140 
Cheloid, 348 
Chemiater, 15 
Chemical analysis of urine, 60 
Chicken broth, 397 
Chicken-pox, 253 
Chieoe, 365 
Chilblain, 354 
Children, consumption in, 146 



406 



INDEX. 



PAGE 

Chills and fever, 266 

Chloasma, 344, 353 

Chlorate of potassa, F. 54 and 

156, 375, 386 

with iron, F. 157, 387 

Chloride of ammonium in urine, 60 

of iron, F. 57, 375 

of sodium in urine, 60 

Chlorinated soda and glycerin, F. 

57, 375 

Chlorodyne, F. 214, 393 

Chloroform, inhalation of, 111 

mixture, F. 91, 379 

and camphor, F. 100, 380 

Hoffmann's anodyne, &c, F. 

49, 374 

liniment, F. 28, 372 

paregoric, Nos. 1 & 2, F. 92, 

93, 379 

Chlorosis, 30, 330 

Cholaemia, 29 

Cholera, 299 

infantum, 179 

morbus, 176 

Cholestersemia, 29 

Cholesterin, 61 

Chorea, 234 

Choreic spasms, 62 

Chronic diarrhoea, 178 

gastritis, 162 

inflammation, 41 

laryngitis, 133 

pleurisy, 127 

Cider mixture, F. 40, 373 

Cinchonated syrup of iron, F. 216, 393 

Cinchonization, 101 

Circulation, symptoms affecting, 49 

Circulatory organs, affections of, 147 

Cirrhosis, 191 

Citrate of iron, F. 23, 371 

magnesia solution, F. 220, 393 

Clark, A., on cholera stages, 313 

Clark, Stewart, premonitions of 

cholera in India, 313 

Classification of diseases, 118 

of remedies, 83 

Clavus, 345 

Clergyman's sore throat, 134 

Climates for the consumptive, 146 

Clitoridectomy, 232, 354 

Clonic spasm, 62 

Coarse crepitant rale, 74 

Cobbold, account of tapeworms, 360-361 

on hydatids of liver, 194 

Cocculus Indicus, F. 211, 392 

Cod-liver oil, F. 30, 79, 372 

in phthisis, 143 

and glycerin, F. 34, 372 

iron and quinine, F. 32, 372 



PAGE 

102 
374 



374 
85 
389 
171 
175 
176 
128 
193 

383 

54 

59 

65 

47 

393 

398 

370 

116 
345 
196 

186 
276 
215 



Colchicum, in gout, 

and alkalies, F. 46, 
and ipecacuanha, F. 182, 
and magnesia, F. 45, 
Cold applications, 

cream with zinc, F. 178, 
Colic, 

prevention of, 
remedies for, 
Collapse of lungs, 
Colloid degeneration of liver, 
Collyriuin of nitrate of silver, F. 

130, 
Color of the skin in disease, 
Coloring matters in urine, 
Coma, 

death by, 
Compound cathartic pills, F. 219, 
rhubarb pills, F. 218, 
spirits of juniper, F. 11, 
Conclusions, general, in therapeu- 
tics, 
Condylomata, 
Congestion of kidneys, 

of the liver, 
Congestive fever, 
Conjunctivitis, 
Constipation, 54, 167 

Constructive antidotes, 101 

Consumption, 139 

Contro-stimulant treatment, 89 

Convulsion, 45, 46, 232 

Copaiba mixture, F. 17, 371 

mixture, F. 174, 388 

Copeland, on fissure of anus, ope- 
ration for, 
Cophosis, 

Cord, spinal, softening of, 
Corneitis, 
Corns, 
Corrosive sublimate lotion, F. 194, 

210, 390,392 

Cough, 53 

Countenance, expression of, in dis- 
ease, 
Counter-irritation, 
Coup de soleil, 
Cow-pox, 
Coxalgia, 
Crackle, dry, 
Craigie, the first case of leucocy- 

thasmia, 
Cramp of stomach, 
Cream of tartar and dandelion, F. 

39, 
Creasote pills, F. 81, 

and glycerin, F. 58, 158 ; 375, 386 

soda, and morphia, F. 68, 376 

Crepitant rale, 72 



185 
219 
214 
217 
345 



65 

91 

219 

251 

328 

72 

331 
174 

373 

378 



INDEX. 



407 



PAGE 

Cretinism, 336 
Croton oil, F. 127, 383 
Croup, 135 
Croupal catarrh, 136 
Cruveilhier's palsy, 229 
Cubebs mixture, F. 175, 388 
Cullen, 18 
Cunisset's test for bile, 56 
Cupping, 88, 89 
Cutaneous affections, 337 
Cutter, E., experiments "with cow- 
pox, 251 
Cyanosis, 50 
Cystine, 57, 61 
Cystitis, 207 
Czermak, laryngoscopist, 77 

DaCosta, on inhalation, 111, 112, 114 

temperature in cancer, 79 

Dance, St. Vitus' 234 

Davaine on hydatids, 194, 206 

Davis, treatment of coxalgia, 329 

Davy, J., temperature in disease, 78 
Deafness, 64, 219 

Death in heart-disease, 153 

modes of, 46 

Decubitus in disease, 62 

Degeneration, 42, 43 

fatty, of the heart, 152 

treatment of, 106, 110 

Definition of disease, 25 

De Haen, temperature in disease, 78 
De Jonnes, Moreau, statistics of 

cholera, 304 

DeLebo, 18 

Delirium, 65 

tremens, 239 

Dementia, 241 

Demme, cranium holder, 80 

Dengue, 265 

Depression, 94, 96 

of the chest locally, 67 

Devergie, spontaneous generation, 351 
Diabetes insipidus, 201 

mellitus, 202 

Diabetic sugar, tests for, 58 

Diagnosis, definition of, 47 

of heart-disease, 75 

Diaphoretics in fever, 93 

Diarrhoea, 177 

Dicrotous pulse, 50 

Diet, in disease, 89 

Digitalis, F. 42, 43, 374 

Digestibility of foods, 167 

Digestive organs, affections of, 156 

system, symptoms connected 
with, 48 

Digitalis, 90 

in heart-disease, 151 | 



PAGE 

Digitalis, squills, &c, F. 38, 373 

Dilatation, bronchial, 132 

of the heart, 151 

of os uteri, 356 

Dimensions of the chest, 67 

Diphtheria, 260 

Diphtheritic paralysis, 228 

Diplopia, 64 

Dipsomania, 240 

Diseases, classification of, 118 

definition of, 25 
Disinfection, 400 
Displacement of organs, from effu- 
sion, &G. f 74 
Distomata, 362 
Diuresis, 54 
Dogmatic medicine, 14 
Donovan's solution, F. 170, 388 
Doses for inhalation, 114 

in hypodermic medication, 116 

Dracunculus, 364 

Drainage in pleuritic effusion, 127 
Drake, on treatment of remittent 

fever, 274 

Dropsies, 246 

Dropsy of the head, 212 

Drowning, 367 

Dry crackle, 72, 74 

Dry sounds in auscultation, 71 
Dubois Raymond, on electricity, 108 
Du Chaillu, prevention of fever by 

quinine, 278, 279 

Duchenne on electricity, 108 

Duchenne's disease, 229 

Dumbness, feigned, 134 
Dundas, quinine in typhoid fever, 290 
Dunglison, treatment of delirium 

tremens, 240 

Dysentery, 180 

scorbutic, 321 

Dysmenorrhcea, 61, 356 

Dysphagia, 48 

Dyspepsia, 164 

Dysphoria, 134 

Dvspnoaa, 52 

Dysuria, 54, 208 

Earache, 218 

Ear, inflammation of, 218 

Ears, sounds in, 64 

Echo, metallic, 74 

Eclampsia nutans, 233 

Eclecticism, 15 

Economic remedies, 83 

Ecthyma, 341 

Eezenia, 339 

Effervescence in urine, 5 7 

Effervescing draught, F. 65, 376 

fever powders, F. 224, 394 



408 



INDEX. 



PAGE 

Effusion, serous, tapping for, 127 

Electricity as a remedy, 107 

Elephantiasis arabum, 345 

graecorum, 348 

Eliminative remedies, 83 

Emaciation, 53 

Embolism, 333 
Empirical medicine, 14, 20, 21, 22, 23 

Emphysema of lung, 128 

Emprosthotonos, 62, 235 

Empyema, 125 

Encephalitis, 209 

Endemic dysentery, 182 

Endocarditis, 149 
Enema of castor oil, k, F. 141, 385 

laudanum and starch, F. 115, 382 

sulphate of zinc and lauda- 
num, F. 116, 382 
Enteric fever, 290 
Enteritis, 168 
Entozoa, 360 
Enuresis, 54, 208 
Ephelis, 344 
Epidemic and sporadic inflamma- 
tions contrasted, 93 
Epilepsy, 230 
Epistaxis, 51, 243 
Episynthetism, 15 
Epizoa, 365 
Equinia, 264 
Ergot, as an antiphlogistic, 90 
Erysipelas, 296 
Erythema, 337 
Essence of beef, 398 
Exanthemata, 337 
Excito-secretory action, 46 
Exclusivism, 108 
Exhaustion, 94 

of the heart, 154 

Ex-ophthalmic goitre, 153 

Expansion of the chest, 67 

Expectant medicine, 22 

Expectoration, 53 

Expiratory murmur, 70 
Expression of the face in disease, 65 

Exudation, 37 

Eyes, changes of disease, 63 

inflammation of, 215 

Facial palsy, 224 

Facies Hippocratica, 65 

Famine fever, 284 

Faradization, 107 
Fatty degeneration of the heart, 152 

liver, 192 

urine, 60 

Favus, 351 
Fawn-colored deposits in urine, 57 

Febrifuge treatment, 93 



PAGE 
Feeble respiration, 73 

Feigned dumbness, 134 

Felon, 334 

Fenwick, detection of lung tissue, 141 



Fermentation test for sugar, 


59 


Fever, pathology of, 


26 


treatment of, 


93 


cerebro-spinal, 


284 


intermittent, 


266 


malarial, 


266 


pernicious, 


276 


puerperal, 


297 


relapsing, 


284 


remittent, 


270 


scarlet, 


254 


typhoid, 


290 


typhus, 


287 


yellow, 


280 


Filaria medinensis, 


364 


Fissure of anus, 


185 


Fleas, * 


365 



305 



61 



Flint, A., against contagion of 
cholera, 

on recovery from consumption, 142 

treatment of cholera, 311 

Flint, Dr. A., Jr., on excretion of 

cholesterin, 
Fluctuation, 
Fluid extract of hyoscyamus, F. 

155, 
Follicular pharyngitis, 

stomatitis, 
Food, digestibility of different 

kinds, 
Forbes, Sir John, 
Formulae, 



380 
134 
157 

167 

17, 22 

368, 369 

Fox, Tilbury, opinion about epi- 
phytes, 350 
Frerichs on Bright's disease, 197 
on pigmentary degeneration, 191 
Friction sounds, 71, 72 
sounds of the heart, 76 
Frost bite, 354 
Fuller, first diagnosis of leuco- 
cythaemia, 331 



Gairdner, succession of typhoid 

and typhus fevers, 
Galvanism as a remedy, 
Galen, 

Gallic acid, F. 146, 
Galloping consumption, 
Gall-stones, 

Ganglio-therapy, 17 

Gangrene of lung, 
Gangraena oris, 

Gastritis, 161, 

Gastrodynia, 166, 

Gastro-hepatic catarrh, 



289 
107 

15 
385 
142 

61 
,84 
128 
158 
162 
238 
161 








INDEX. 




409 


PAGE 


♦ 


PAGE 


Greiger, lime-water in diphtheria, 


113 


Heart, dilatation of, 




151 


General paralysis of insane, 


229 


diseases of, 




147 


pathology, 


25 


enlargement of, 




151 


therapeutics, 


83 


exhaustion of, 




154 


vital condition, 


65 


fatty degeneration of, 




152 


Gentian and rhubarb pills, F. 73, 


377 


phj^sical diagnosis of, 




75 


and rhubarb, tincture, F. 72, 


377 


sounds of, 




75 


rhubarb and blue mass, F. 74, 


377 


sounds, heard at a distance, 


74 


Gerhard on tubercular meningitis, 


211 


Heat-stroke, 




219 


Gin liver, 


191 


Ilebra, opinion about epiphytes, 


350 


Glanders, 


264 


Heller's test for bile, 




56 


Glisson's capsule, inflammation of, 




Hemicrania, 




238 


in cirrhosis, 


191 


Hemiopia, 




64 


Glucose, tests for, 


58 


Hemiplegia, 


63 


225 


Glyceramyl, F. 148, 


385 


Hemorrhage, 


51 


242 


Glycerin ointment, F. 233, 


395 


from bowels, 




245 


and rose water, F. 50, 


374 


from kidneys, 




245 


Glycerole of lead, F. 180, 


389 


uterine, 




246 


of zinc, F. 177, 


389 


Henle, 




18 


Glycosuria, 


202 


Hepatitis, 




187 


Gnielin's test for bile, 


56 


Hepatization, 




122 


Goitre, 


336 


Herpes, 




340 


Gonorrhoea, 


324 


Hiccough, 




53 


Gonorrhoeal ophthalmia, 


216 


Hip disease, 




328 


rheumatism, 


318 


Hippocrates, 


13, 14, : 


Gout, 


317 


Hob-nailed liver, 




191 


treatment of, 


102 


Hoffmann, 




16 


Gouty colic, 


174 


Hoffmann's anodyne, ammonia, 




Gravel, 


200 


and soda, F. 47, 




374 


Griscom, J. H., mortality from 




Hoffmann's anodyne, squills 


, and 




cholera in New York, 


302 


morphia, F. 36, 




373 


Guaiacum, F. 167, 


387 


Homoeopathy, 




17 


GUggenbuhl, cure of goitre, 


336 


Hooping-cough, 




258 


Guinea worm, 


364 


Hope's mixture, F. 221, 




394 


Gums, signs of disease concerning, 


48 


Horner, anatomy of cholera, 




299 


Gurgling, 72, 74 


Horner, W. E., treatment of cho- 








lera, 




312 


Haamatemesis, 51, 52, 


245 


Hosack, 




18 


Hematuria, 52, 


245 


Hot air bath, 




109 


Haemorrhoids, 


182 


Humid crackling, 


72, ' 


Haemoptysis, 


51 


Humoralism, 




18 


Hale, E., on continued fever, 


289 


Hunter, C, on hypodermic medi- 




Hallier, classification of epiphytes, 


351 


cation, 


114, 


115 


Hammond, W. A., on heat in pa- 




Hunter, John, 




16 


ralysis, 


230 


Hutchinson, on spirometry, 




68 


Hammond, on lesions in mountain 




Hybrid, between scarlatina 


and 




fever, 


293 


measles, 




257 


Hammond's alterative for syphilis, 




Hydatids of kidney, 




206 


F. 215, 


393 


of liver, 




194 


Handfield Jones, inhibitory action, 


227 


Hydrocephalus, 




212 


Harley, diagnosis of jaundice, 29, 


189 


Hydrocyanic acid, F. 20, 




371 


Harsh respiration, 


73 


Hydropathy, 




108 


Hartshorne, Joseph, treatment of 




Hydronephrosis, 




204 


tetanus, 


256 


Hydrophobia, 




236 


Harvey's account of valvular affec- 




Hydro-pneumothorax, 


125, 


140 


tions, 


75 


Hygienic management of 


con- 




Haven, on intestinal obstruction, 


175 


sumption, 




143 


Headache, 


64 


Hyperaema: sthesia, 




42 


sick, 


161 


treatment of, 




91 


35 











410 


INDEX. 




• 


PAGE 




PAGE 


Hyperesthesia, 


45 


Inspection of the body after death, 


Hypertrophic, 


344 




80. 81 


Hypertrophy, 


33 


Intercostal neuralgia, 


139 


of the heart, 


151 


Intermittent fever, 


266 


Hypodermic medication, 


114 


Intestinal hemorrhage, 


245 


Hyposulphite of soda, 


104 


obstruction, 


175 


Hysteria, 


237 


Intussusception, 


175 


Hysterical paralysis, 


227 


Iodide of iron, F. 33, 


372 


Hysterotomy, 


356 


of lead ointment, F. 239, 


396 






of mercury, F. 169, 


388 


Iatromechanicism, 


15 


of potassium, F. 61, 


375 


Ichorhsemia, 


332 


of potassium, F. 140, 


384 


Ichthyosis, 


343 


of potassium, F. 168, 


388 


Icterus, 


188 


of potassium and glycerin 


F. 


Impetigo, 


341 


198, 


391 


Incontinence of urine, 


54, 208 


Iodide of potassium and iodid 


3 Of 


Inductive Medicine, 


23 


sulphur, F. 199, 


391 


Infancy, ophthalmia of, 


216 


of sulphur ointment, F. 188, 390 


Infants' colic, 


173 


ointment, F. 231, 


395 


Infantile paralysis, 


229 


Ipecacuanha and alum, F. 24, 


371 


Inflammation, 


35 


in inflammation, 


90 


of bladder, 


207 


Iritis, 


217 


bowels, 


168 


Iron in anaemia, 


97 


brain, 


209 


quinine and strychnia, syrup, 


bronchiae, 


129 


F. 213, 


392 


ear, 


218 


Irregularity of pulse, 


50 


endocardium, 


149 


Irritation, 


35 


eye, 


215 


spinal, 


215 


kidney, 


197 


Ischuria, 


54. 208 


larynx, 


133 


Itch, 


351 


liver, 


187 






lungs, 


121 


Jackson, Professor, on repose, 


100 


lymphatics, 


333 


Jail fever, 


287 


mouth, 
pericardium, 


156 
147 


Jalap and squills, F. 151, 
Jaundice, 


386 
188 


peritoneum, 
pharynx, 


169 
160 


Jenner,W., on typhus and typhoid 
fevers, 289 


pleura, 


125 


Jewell, J. S., on cerebro-spinal 


spinal marrow, 

stomach, 

tonsil, 

trachea, 

veins, 


213 
161 
159 
135 
133 


meningitis, 287 
Johnson, Gr., on Bright's disease, 197 
on cholera, 310 
Jones, Handfield, on inhibitory 

action, 227 


remedies for, 
Influenza, 
In-growing nail, 


92 
264 
334 


Juniper infusion, F. 12, 
tar soap, F. 190, 


370 
390 


Inhalation, 


111 






Injection for gonorrhoea, F. 


171, 


Keloid, 


348 


172, 


388 


Keratitis, 


217 


Inman, on counter-irritation, 


92 


Kidney, affections of, 


196 


on myalgia, 


317 


cancer of, 


205 


observations on secretions, 60 


congestion of, 


196 


Inoculation, introduction of, 


251 


hydatids of, 


206 


Insane, general paralysis of, 


229 


tubercle of, 


205 


Insanity, 


241 


Kinesipathy, 


110 


expression of, 


65 


Kiichenmeister, lime-water 


in 


Insolatio, 


219 


diphtheria, 


113 


Insomnia, 


220 


Kursack, hypodermic medication, 1 


Inspection, 


66 


Kye stein, 


60 



INDEX 



411 



PAGE 

18 



tre- 



Laennec, 

Lallernand, pathology of sperma- 
torrhoea, 

porte-caustique, 
Language, theory concerning, 

founded on aphasia, 
Lardaceous liver, 
La Roche, the authority on yellow 

fever, 
Laryngoscope, 
Laryngitis, 

Laryngismus stridulus, 
Laycock, 

facts concerning cholera, 

treatment of delirium 
mens, 
Laxatives in fever, 
Lead and morphia mixture 
104, 

colic, 

ointment, F. 179, 

palsy, 

Lead-water for the eyelids, F. 128, 383 
Leared, table of articles of food, 167 
Lebert, 
Lee, B., angular curvature of the 

spine, 
Leeches, 
Lehmann, 
Lepra, 

Leprosy of the Bible, 
Leucocytheemia, 30, 331 

Leucorrhoea, 357 

Levick on spotted fever, so called, 287 
Levret, designer of the laryngo- 



F. 



358 
359 

135 
193 

282 
77 

133 

135 
19 

315 

240 
93 

380 
172 

389 
228 



20 

328 

88 

18 

342 

343 



scope, 
Liebisr, 



77 

18 

398 



Liebig's broth, 

food for infants, 
Lice, 
Lichen, 
Lime, syrup of, Trousseau's, F. 

242, " 396 

Lime-water and milk, F. 64, 376, 397 
Lind, use of antiscorbutics, 320 

Liquid Dover's powder, F. 225, 394 
Liquorice and opium lozenges, F. 

237, 
Lithiasis, 
Liver, affections of, 

abscess of, 

acute yellow atrophy of, 

cancer of, 

fatty, 

hydatids of, 

pigmentary degeneration of, 

syphilitic, 

tubercle of, 

waxy, 



365 
338 



395 
200 
186 
187 
190 
194 
192 
194 
191 
193 
195 
193 



PAGE 

Livingstone, prevention of fever, 278 
Lobelia and ipecacuanha, F. 18, 371 
Lock-jaw, 235 

Locomotor ataxy. 229 

Lordat, on aphasia, 135 

Lotion for the ear, F. 132, 384 

Louis, 18, 23 

on dothinenterite, 289 

pleximeter, 68 

Lozenges for hoarseness, F. 236, 395 
Lugol's solution, F. 176, 388 

Lumbricoid worms, 362 

Lund, craniotome, 80 

Lupus, 347 

Lymph corpuscles, 38 

inflammatory, 38, 39 

Lyons, on general vital condition, 65 



Maculae, 

Magnesia and ammonia mixture, 
F. 99, 

sulphite of, 
Malarial fever, 
Mania, 

a potu, 
Marriage of consumptives impro- 
per, 
Mason G-ood, account of leprosy, 
Maumene's test for sugar, 
Maxims, therapeutic, 
McClellan, E., chloroform in de- 
lirium tremens, 
McDonell on liver-sugar, 
Measles, 

Mediate percussion, 
Medico-legal examinations, 
Meigs, C. D., pathology of cholera, 
Melancholia, 
Mel anaemia, 
Melasma supra-renalis, 
Membranous croup, 
Meningitis, 

spinal, 

cerebro-spinal, 
Menorrhagia, 61, 

Menstruation, and its deviations, 
61, 66 
Mentagra, 
Mercurial palsy, 

sore mouth, 
Mercury, in inflammation, 

with chalk and cinnamon, F. 
108, 
Merrill, treatment of intermittent 

by chloroform, 
Metallic tinkling, 73 

Metamorphosis of tissue, retarda- 
tion, 
Methodism, 



344 

380 
105 
266 
241 
239 

143 
343 

58 
117 

240 

203 

256 

68 

81 

304 

241 

30 

335 

137 

209 

213 

284 

357 

, 67 
352 
228 
158 
90 



269 
, 74 



99 
14 



412 



INDEX. 



PAGE 

Methoniania, 240 

Mialhe, theory of gout, 319 

Miasmatic typhoid fever, 279 

Microscopic examination of urine, 

58, 60 
Milk, in disease, 61 

Millon's test for albumen, 58 

Milroy, Gavin, on localities ex- 
empt from cholera, 303 

on quarantine against cholera, 307 
Mitchell, J. K., fungous theory of 

.fevers, 268 

S. W., on reflex paralysis, 227 
Moist sounds, 72 

Moles, 344 

Moleschott, 18 

Molluscum, 346 

Monomania, 241 

Moore's test for glucose, 58 

Morbilli, 256 

Morbus Addisonii, 30 

Morbus coxarius, 328 

Morell, 19 

Morgagni, case of reflex paralysis, 227 
Morphia with valerian, F. 144, 385 
Morsen, C, cryptogamic causation 

of ague, 268 

Mortality from cholera, 304 

Mouth, inflammation of, 156 

Movement-cure, 110 

Mucous rale, 74 

Mucus in urine, 58 

Muguet, 157 

Mulberry calculus, 60 

Mumps, 258 

Muriate of ammonia, F. 16, 371 

Muriatic acid and honey, F. 55, 375 
Murmur, vesicular, 70 

Murmurs of the heart, 75 

Musc88 volitantes, 64 

Muscular debility in disease, 62 

Musk mixture, F. 19, 371 

Mustard bathing, 100 

Myalgia, 63, 215, 317 

thoracic, 139 

Myelitis, 213 

Myocarditis, 148 



Naevus, 


344 


Nail, in-growing, 


334 


Naturalism, 


17 


Nausea, 


49 


Nephritis, 


197 


Nervous debility, 


97 


system, affections of, 


209 


Nettle-rash, 


337 


Neuralgia, 


238 


cutis, 


350 


Neuropathology, 16, 44, 45, 46 



PAGE 

Neuroses. 119 
Neutral mixture, F. 149, 385 
Newington, S., on mustard bath- 
ing, 110 
Night terrors, 221 
Nitrate of potassa, F. 4, 369 
in inflammation, 90 
silver in chronic inflam- 
mations, 133 
pills, F. 62, 375 
solution, F. 2Q f 372 
urea, 59 
Nitric acid, F. 166, 387 
Nitromuriatic acid, F. 21, 371 
Ac, F. 165, 387 
Nosology, 118 
Nummular sputa, 140 
Nurses' sore-mouth, 159 
Nutmeg liver, 191 
Nux vomica, tincture, F. 34, 372 
colocynth, and soap, F. 

84, 378 
iron, and quinine, F. 

71, 377 

Oat-meal gruel, 397 

Obstruction of bowels, 175 

Odontalgia, 239 

(Edema of the glottis, . 133 

(Esophagus, stricture of, 161 

Oidium albicans, 157 

Oil of cajuput, F. 79, 378 

turpentine mixture, F. 157, 385 

Oinomania, 240 

Ointment of galls and opium, F. 

118, ~ 382 
Olive oil and laudanum, F. 133, 384 

Onychia, 334 

Onyxis, 334 

Opaque urine, 55 

Ophthalmia, 215 

Ophthalmoscope, 218 

Opisthotonos, 62, 235 

Opium, in inflammation, 91 

and ipecacuanha, F. 87, 378 

camphor, and hyoscyamus, F. 

145, 381 

suppositories, F. 124, 383 
Oppression, 94, 95 
Organic degeneration, manage- 
ment in, 110 
Organography, 66 
Organs, general pathology of, 33 

morbid states of, 25 

Orthopnoea, 52 

Otalgia, 218 

Otitis, 218 

Ovarian dropsy, 247 

Oxalates in urine, 57 



INDEX. 



413 



PAGE 

Oxalate of lime calculus, 60 

Oxide of zinc ointment, F. 181, 389 
Oxyurus vermicularis, 3G3 



Pain, 

Palpation, 
Palpitation, 
Palsy, 
Panada, 



63, 84 

6, 67, 68 

49, 154 

224 

397 



Papavoine, on tubercular menin- 
gitis, 211 
Papulae, 338 
Paralysis, 45, 63/224 

agitans, 229 

infantile, 229 

reflex, 227 

Paraplegia, 63, 226 

Parasitica, 350 

Paronychia, 334 

Parotitis contagiosa, 258 

Pavy, cure of hydatids of liver, 195 

on liver-sugar, 203 

Pectoriloquy, 73, 74 

Pemphigus, 341 

Pepsin, Boudault's, 166 

Percussion, 66, 68 

Pereira, on electricity, 108 

Pericarditis, 147 

Peritonitis, 169 

Peri-typhlitis, 196 

Pernicious fever, 276 

Perspiration in disease, 61, 62 

Pertussis, 258 

Petechial fever, 284 

Pettenkofer's test for bile, 56 

view of cholera, 306 

Pharyngitis, 160 

Phlebitis, 332 

Phlegmasiae, 118 

Phosphate of iron, P. 142, 385 
Phosphates and hypo-phosphites, 97 

in urine, 57 

Phosphate of lime calculus, 60 

Phosphorus pills, P. 241, 396 

Photophobia, 64 

Photopsia, 64 

Phrenitis, 209 

Phthisis pulmonalis, 139 

in early life, 146 

Physical diagnosis, 66 
Physick, treatment for coxalgia, 329 

Physiological medicine, 20 

Pigment liver, 191 

Piles, 182 

Piorry, on diminution of spleen 

under cinchonism, 196 
Piorry's pleximeter, 68 
Pitch, in auscultation and percus- 
sion, 70, 71 



£53 
121 
140 

140 
318 
378 
384 
379 
365 



269 



PAGE 

Pitting, in smallpox, prevention 

of, 250 

Pityriasis, 313 

versicolor, 353 

Plague, 295 

Playfair, venesection in cholera, 309 
Pleurisy, 125 

Pleurodynia, 139, 238 

Pleximeters, 68 

Plica polonica, 
Pneumonia, 
Pneumo-hydrothorax, 
Pneumothorax, 
Podagra, 
Podophvllum, etc., F. 82, 

pills, F. 136, 

rhubarb, etc., F. 95, 
Poisons, 
Poisoning, suspected, directions 

concerning, 81, 82 

Poison-vine eruption, 354 

Pollacion, chloroform in intermit- 
tent, 
Polli, on sulphites and hypo-sul 

phites, 
Polyuria, 
Pompholyx, 
Porrigo, 
Position of body in disease, 

in treatment of disease 
Post-mortem examination, 

signs of inflammation, 
Practice of medicine, 
Pregnancy, convulsions of, 
Prepared chalk and gum arabic, 

F. 51, 
Pretubercular stage of phthisis, 
Prevention of cholera, 

of colic, 

of yellow fever, 
Prognosis, 

Progressive locomotor ataxy, 
Prolapsus ani, 
Proliferation of cells, 
Prolonged expiration, 
Prophylaxis of cholera infantum 

of malarial fever, 
Prost, on typhoid fever, 
Protective remedies, 
Prurigo, 

Pseudo-membranous croup, 
Psoriasis, 
Psychical apparatus, symptoms 

connected with, 65 

Puerile respiration, 70, 73 

Puerperal convulsions, 233 

Pulmonary apoplexy, 244 

gangrene, 128 

Pulsatile vibration, 68 



103 

201 

341 

351 

62 

85 

80, 81 

40, 41 

121 

233 



374 
140 
307 
175 
283 

47 
229 
186 

37 

70 
180 
278 
2S9 

83 
349 
137 
342 



35* 



414 



INDEX, 



PAGE 

Pulsation of veins, 50 
Pulse, 49, 50 

Pupil, in disease, 64 

Purging, in inflammation, 89 

Purpura, 348 

Purpurine, 56 

Purring vibration, 68 

Purulent ophthalmia, 216 

Pus, 40 

in urine, 58 

Pustulse, 341 

Pyaemia, 28, 232 

Pyelitis, 197 

Pyonephrosis, 204 

Pyrosis, 167 

Pythogenic fever, 290 

Quinine pills, F 159, 387 

solution, F. 2, 389 

and chloride of iron, F. 222, 394 

and iron pills, F. 162, 387 

for children, F. 223, 394 
ipecac, camphor, and opium, 

F. 117, 382 

Quinsy, 159 

Rachitis, 327 

Radcliffe on electricity, 108 
Radcliffe's phosphorus pills, F. 

241, 396 
Rage, in hydrophobia, &c, 65 
Rale, crepitant, 72 
Rawiollissement of the brain, 213 
Rasori, 3 6 
Rationalism, 20 
Rational symptoms, 47 
Reagents for examination of urine, 60 
Rectum, prolapsus of, 187 
Recuperative remedies, 83 
Red sand in urine, 51 
Reducing treatment, 87 
Reese, Prof., directions for med- 
ico-legal examinations, 81 
Reflex paralysis, 227 
Regions of the chest, 66 
Reid, J., case of leucocythaemia, 431 
Relapsing fever, 284 
Remak, on electricity, 108 
Remedies, classification of, 83 
for colic, 176 
Remittent fever, 270 
Renal hemorrhage, 245 
Resin of jalap, F. 135, 384 
Resistance in percussion, 69 
Resonance, characters of, 68, 69 
Respiration, symptoms affecting, 52 
Respiratory organs, affections of, 121 
Rest, 85, 100 
Retention of urine, 55 



PAGE 

Retraction of the chest, 67 

Retropharyngeal abscess, 160 

Rhatany and paregoric, F. 110, 381 

Rheumatism, 315 

treatment of, 102 

Rheumatoid arthritis, 317 

Rhinoscopy, 78 

Rhonchal vibration, 67 

Rhonchi, 72 

Rhubarb pills, F. 75, 377 

and aloes, F. 67, 377 

and colocynth, F. 76, 377 

magnesia, and charcoal, F. 

238, 396 

Rice-water, 397 

Richardson, B. W., lactic acid in 

rheumatism, 316 

management of consumption, 143 

Richardson's spray -producer, 113 

Rickets, 327 

Ring-worm, 352 

Roberts on Bright's disease, 197 
Rokitansky on matter of typhoid 

lesion, 292 
Roseola, 338 
Round worms, 362 
Rubbing vibration, 58 
Rubeola, 257 
Rufz on tubercular meningitis, 211 
Rupia, 341 
Ruppaner on hypodermic medica- 
tion, 116 
Rupture of spleen, 195 
Rush, 17 
Rynd, hypodermic medication, 114 

Sago jelly, 389 

Salaam convulsions, 233 

Sales-Girons' inhaler, 112 

Saline draught, Stevens', F. 240, 396 
Salisbury, Dr., experiments in 

production of measles, 257 

observations on causation of 

intermittent by palmellce, 268 

Salivation, 158 

Salts, earthy, in urine, 57 

Sanctorius, 15 

Sanderson, artificial diphtheria, 262 
Sanitary police the prevention of 

cholera, 308 

Santonin, F. 206, 391 

suppository, F. 209, 392 

Sarcina, 49 

Sassafras liniment, F. 139, 383 

Scabies, 351 

Scald-head, 352 

Scarlatina, *** 253 

rheumatica, 265 

Sciatica, 238 



INDEX. 



415 



Sclerostoma duodenale, 

Scorbutic dysentery, 

Scrivener's palsy, 

Scrofula, 

Scrofulosis, 

Scudaraore's mixture, modified, 
F. 227, 

Scurvy, 

Scybala, 

Seasickness, constipation in, 

Seats of disease, 

Seat-worms, 

Secretions in fever, 

symptoms connected with, 

Secretory sounds in auscultation, 

Sedative lotion, F. 196, 

Sediments in urine, 

Seidel, friction sounds in peritoni- 
tis, 

Semeiology, 

Semeleder on laryngoscopy, 

Seminal weakness, 

Senna and pink-root infusions, 
fluid extract, F. 208, 

Sensory apparatus, symptoms con- 
nected with, 

Septicaemia, 

Serpents, bites of, 

Ship fever, 

Sibilant rhonchus, 

Sick headache, 

Siegle's inhaler, 

Sigmund, Dr., case of aphasia, 

Simon, J., limitations of the term 
pyaemia, 

Simpson, treatment of dysmenor- 
rhoea and sterility, 

Sims, Marion, on dysmenorrhoea, 

Singultus. 

Skin diseases, 

secretion of. in disease, 
symptoms affecting, 

Skoda, classification of percussion 
sounds, 
of auscultatory sounds, 

Skoda's pleximeter, 

Smallpox, 

Smith, Southwood, against conta- 
gion of cholera, 

Snow, Dr., of Providence, against 
contagion of cholera. 

Soda and nitre, F. 122, 
powders, F. 226, 

Softening of the brain, 
of stomach, acute, 

Solidism, 

Sonorous rhonchus, 

Sore throat, 

Sounds of the throat, 



PAGE : PAGE 

304 Southam, treatment of calculus, 201 
321 Spasm, 82 
225 Specific gravity of urine, 56 
326 J inflammations, 40 

31 Spedalsked, 343 
I Spermaceti ointment and opium, 

394 119, 3S2 

320 Spermatorrhoea, 358 

176 Spermatozoa, 58 

168 Spice poultice, F. 70, 376 

25 Spiced rhubarb and magnesia, F. 
363 101, 380 

26 Spinal irritation, 215 
54 marrow, inflammation of, 213 
71 meningitis, 213 

390 Spiritus mindereri with nitre, F. 

57 150, 386 
Spirometry, 66, 68 

77 Spleen, affections of, 195 

47 Splenization, ]22 

77 Sponge tent, F. 243, 396 

358 Sporadic and epidemic inflamma- 

207 tions contrasted, 93 

392 Spotted fever, 2S4 

i Squama?, 342 

63 Squills and digitalis, F. 10, 370 

332 and paregoric, F. 15, 379 

367 and tartar emetic, F. 14, 370 

287 nitre and digitalis, F. 13, 370 

72, 74 Stata, 16 

161 ! Stethoscope, 70 
113 Stercoraceous vomiting, 49 
135 | Stercorin, 61 

J Sterility, treatment of, 356 

332 J Stertorous breathing, 53 

Stevens' saline treatment of chol- 

356 era, 310 

356 saline draught, F. 240, 396 

53 Stewardson, T., on morbid anato- 

337 my of remittent fever, 272 
62 Stewart, A. P., of Glasgow, on ty- 

53 phoid fever, 289 
Sthenic and asthenic inflamma- 

70 tions, 92 

71 system, 16 

58 Stimulant treatment, 94, 96, 98 
249 Stimulating embrocation, F. 185, 389 

liniment, F. 138, 384 

305 Stimulation, 35 
Stimulism, IS, 199 

305 ! Stokes on thyro-cardiac disorder, 153 

383 Stomach, acute softening of, 162 

394 cancer of, 164 

213 cramp of, 174 

162 inflammation of, 161 
16 ulcer of, 162 

72, 74 Stomatitis, 156 

160 Stone, 200 

75 ( Storer, H. R., on hysterotomy, 356 



416 



INDEX. 



Strangury, 

Stricture of oesophagus, 

Strongylus gigas, 

Strophulus, 

Strumous diathesis, 

Strychnia, F. 137, 

in paralysis, 
St. Vitus' dance, 



PAGE 

208 
161 
364 
338 
326 
384 
97 
234 

Subnitrate of bismuth, F. 63, 376 

Subsultus tendinum, 62 

Succussion, 66 

Sudden death, 47 

in heart disease, 153 

Suffocation, 367 

Sulphate of cinchonia pills, F. 161, 387 

solution, F. 160, 387 

of zinc and rose-water, F. 53, 375 

Sulphite of soda, F. 152, 386 

of soda and glycerin, F. 184, 389 

Sulphites and hyposulphites, 103 

Sulphur ointment, F. 235, 395 

Sulphuret of potassium ointment, 

F. 183, 289 

Sulphuro-alkaline ointment, F. 

197, 391 

Summer complaint, 179 

Sun-stroke, 219 

Supporting treatment, 94 

Suppository of soap, F. 83, 378 

Suppression of urine, 196 

Suppuration, 40 

Sycosis, 352 

Sydenham, 16 

Symptomatology, 47 

Syncope, apoplectiform, 152 

Syphilida, 353 

Syphilis, 322, 323 

conveyed by vaccination, 252 

Syphilitic iritis, 218 

liver, 193 

paralysis, 228 

Syphilization, 324 

System, morbid states of, 25 

Taenia, 360 

Tannic acid and opium, F. 106, 381 
acid solution, F. 60, 375 

acid wash, F. 121, 382 

Tannin lotion, F. 205, 391 

Tapeworm, 360 

Tapioca, 398 

Tar ointment, F. 232, 395 

Tartar emetic, F. 1, 89, 369 

Taste, in disease, • 48 

Taylor, C. T., on infantile paraly- 
sis, 229 
Teeth, signs of disease concern- 
ing, 48 
Tegument, symptoms affecting, 53 



PAGE 

Temperature in disease, 78, 79 

Tenderness on pressure, 63 
Tentative antidotal treatment, 101 
Terror, expression of, in delirium 

tremens, 65 

Tetanus, 235 

Tetrastoma, 362 
Tetter, 339, 340 

Therapeutics, general, 83 

Thiersch's view of cholera, 306 

Thoracic myalgia, 139 

Thrombosis, 332 

Thrush, 157 

Thy ro- cardiac disorder, 153 
Thyroid gland, enlargement of, 336 

Ticks, 365 

Tic douloureux, 238 

Tilt, on hysterotomy, 356 

Tinea circinatus, 352 

decalvans, 353 

favosa, 351 
Tinnitus aurium, 64 
Tinkling, metallic, 73, 74 
Tissue metamorphosis, retarda- 
tion of, 99 
Toast-water, 397 
Todd, 18 
Todd, practice of, 99 
Tongue, symptoms concerning, 48 
Tonic spasm, 62 
Tonsillitis, 159 
Toothache, 239 
Torula, 49 
Toxaemia, 27 
Tracheitis, croup, 135 
Tracheotomy in croup, 137 
Trichina, 363 
Tricocephalus dispar, 363 
Triple phosphate, 58, 60 
Trismus nascentium, 235 
Trommer's test for glucose, 58 
Trousseau, 18, 20 
Trousseau's syrup of lime, F. 242, 396 
Tubercle, 31 
Tubercula, 346 
Tubercle of kidney, 205 

of liver, 195 

Tuberculosis, 31 

Tuberculous meningitis, 211 

Tiirck, laryngoscopist, 77 

Tympanitic sound, 68 

Typhlitis, 169 

Typhoid fever, 290 

Typho-malarial fever, 279 

Typhoid pneumonia, 124 

state in remittent fever, 271 

Typhus fever, 287 



Ulcer of stomach, 



163 



INDEX. 



417 



PAGE 

Ulcerated sore-throat, 160 

Uraemia, 29, 196 

Urates, 57 

Urea, excess of, 59 

Uric acid, 57 

Urinary calculi, 60 
Urination, symptoms connected 

with, 54 

Urine, incontinence of, 208 

retention of, 208 

Urostealith, 60 

Urquhart, on hot air bath, 109 

Urticaria, 337 

Uterine hemorrhage, 52 

Vaccination, 251 
Valves of the heart, 75, 76 
Valvular affections from endocar- 
ditis, 149 
disease of the heart, 150 
Vanburen, W. H., operation for 

fissure of anus, 185 

Van Helmont, 16 

Varicella, 253 

Variola, 241 

Varioloid, 251 

Vegetable soup, 397 

Veins, pulsation of, 50 

Velpeau, view of cholera, 304 

Venesection, 85 

Venous circulation in disease, 50 

Veratria ointment, F. 29, 372 

Veratrum viride, F. 44, 90, 374 

Verruca, 345 

Vesiculae, 339 

Vesicular murmur, 70 
Vibration of the walls of the chest, 

changes in, 67 

Vibriones, 49 

Vigilance, morbid, 220 

Virchow, 19 

pathology of leukaemia, 331 

theory of inflammation, 37, 86 

Vital condition, 65 

Vitalism, 19 
Vitality, depressed, its effect upon 

secretions, 60 

Vitiligo, 344 

Vocal, resonance, 74 

Voice, loss of, 333 

Volatile liniment, F. 230, 395 



Vomiting of blood, 
as a symptom, 



PAGE 

245 

49 



Wakefulness, 220 

Walshe's pleximeter, 68 
Warner's cordial and laudanum, 

F. 48, 374 

Warts, 345 

Wasting palsy, 229 

Water, a remedy in fever, 93 

Waxy liver, 193 

Wedl, Carl, on typhoid deposit, 292 

West, Charles, on clitoridectomy, 359 

on night-terrors, 221 

Whisper, modified, in auscultation, 72 
White precipitate ointment, F. 

187, 390 

Whitlow, 334 
Wild cherry and lactucarium, F. 

35, 373 

Wilson, E., denial of epiphytes, 350 

on hot air bath, 109 

Wine of ipecacuanha, F. 5, 369 

Winter fever, 124 

Womb, hemorrhage from, 246 

Wood, A., hypodermic medication, 114 
Gr. B., against contagion of 

cholera, 305 
on predisposition to en- 
teric fever, 292 
H. C, Jr., temperature in 
sun -stroke, 78 
Woodward's students' microscope, 60 
Worms, 360 
Worms, Jules, sulphuric acid in 

cholera, 311 

Wrist drop, 228 

Writer's cramp, 225 

Wunderlich's pleximeter, 68 
Wunderlich, temperature in disease, 7S 
Wyman's apparatus for paracen- 

tesis, 127 

Wynne, James, report on cholera, 306 

Yellow atrophy of liver, acute, 190 

fever, 280 

wash, F. 229, 395 

Zymoses, 118 

Zymosis, 28 

Zymotic diseases, 249 

treatment of, 102 



NEILL & SMITH'S COMPENDIUM. 



AN ANALYTICAL COMPENDIUM OF THE VARIOUS 

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LUDLOW'S MANUAL OF EXAMINATIONS. 



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and enlarged. With 370 illustrations. In one handsome royal 12mo. vol- 
ume of 816 large pages,- extra cloth, $3 25; leather, $3 75. 
The arrangement of this volume in the form of question and answer renders 
it especially suitable for the office examination of students, and for those pre- 
paring for graduation. 

We know of no better companion for the student during the hours spent in the lecture- 
room, or to refresh, at a glance, his memory of the various topics crammed into his head 
by the various professors to whom he is compelled to listen. — Western Lancet. 

As it embraces the whole range of medical studies it is necessarily voluminous, con- 
taining 81 6 large duodecimo pages. After a somewhat careful examination of its contents, 
we have formed a much more favorable opinion of it than we are wont to regard such 
works. Although well adapted to meet the wants of the student in preparing for his 
final examination, it might be profitably consulted by the practitioner also, who is most 
apt to become rusty in the very kind of details here given, and who, amid the hurry of 
his daily routine, is but too prone to neglect the study of more elaborate works. The 
possession of a volume of this kind might serve as an inducement for him to seize the 
moment of excited curiosity to inform himself on any subject, and which is otherwise 
too often allowed to pass unimproved. — St. Louis Med. and Surg. Journal. 

HENRY C. LEA-Philadelphia. 



DUNGLISOH'S MEDICAL DICTIONARY. 

MEDICAL LEXICON; A Dictionary of Medical Science: Con- 
taining a concise explanation of the various Subjects and Terms of Anatomy, 
Physiology, Pathology, Hygiene, Therapeutics, Pharmacology, Pharmacy, 
Surgery, Obstetrics, Medical Jurisprudence, and Dentistry. Notices of Cli- 
mate and of Mineral Waters; Formulae for Officinal, Empirical, and Dietetic 
Preparations ; with the Accentuation and Etymology of the Terms, and the 
French and other Synonymes ; so as to constitute a French as well as English 
Medical Lexicon. By Robley Dunglison, M. D., Professor of Institutes of 
Medicine in Jefferson Medical College, Philadelphia. Thoroughly Revised, 
and very greatly Modified and Augmented. In one very large and handsome 
royal octavo volume of 1048 double-columned pages, in small type; strongly 
done up in extra cloth, $6 ; leather, raised bands, $6 75. 
The object of the author from the outset has not been to make the work a 
mere lexicon or dictionary of terms, but to afford, under each, a condensed view 
of its various medical relations, and thus to render the work an epitome of the 
existing condition of medical science. Starting with this view, the immense 
demand which has existed for the work has enabled him, in repeated revisions, 
to augment its completeness and usefulness, until at length it has attained the 
position of a recognized and standard authority wherever the language is spoken. 
The mechanical execution of this edition will be found greatly superior to that 
of previous impressions. By enlarging the size of the volume to a royal octavo, 
and by the employment of a small but clear type, on extra fine paper, the ad- 
ditions have been incorporated without materially increasing the bulk of the 
volume, and the matter of two or three ordinary octavos has been compressed 
into the space of one not unhandy for consultation and reference. 

It would be a work of supererogation to bestow a word of praise upon this Lexicon. 
We can only wonder at the labor expended, for whenever we refer to its pages for infor- 
mation we are seldom disappointed in finding all we desire, whether it be in accentua- 
tion, etymology, or definition of terms. — New York Medical Journal, November, 1865. 

It would be mere waste of words in us to express our admiration of a work which is 
so universally and deservedly appreciated. The most admirable work of its kind in the 
English language. As a book of reference it is invaluable to the medical practitioner, 
and in every instance that we have turned over its pages for information we have been 
charmed by the clearness of language and the accuracy of detail with which each 
abounds. We can most cordially and confidently commend it to our readers. — Glasgow 
Medical Journal, January, 1866. 
A work to which there is no equal in the English language. — Edinburgh Med. Journ. 
It is something more than a dictionary, and something less than an encyclopaedia. 
This edition of the well-known work is a great improvement on its predecessors. The 
book is one of the very few of which it may be said with truth that every medical man 
should possess it. — London Medical Times, Aug. 26, 1865. 

Few works of the class exhibit a grander monument of patient research and of scien- 
tific lore. The extent of the sale of this lexicon is sufficient to testify to its usefulness, 
and to the great service conferred by Dr. Robley Dunglison on the profession, and indeed 
on others, by its issue. — London Lancet, May 13, 1865. 

It is as necessary a work to every enlightened physician as Worcester's English Dic- 
tionary is to every one who would keep up his knowledge of the English tongue to the 
standard of the present day. It is, to our mind, the most complete work of the kind 
with which we are acquainted. — Boston Med. and Surg Journal, June 22, 1865. 

We are free to confess that we know of no medical dictionary more complete ; no one 
better, if so well adapted for the use of the student ; no one that may be consulted with 
more satisfaction by the me'dical practitioner. — Am. Journ. Med. Sciences, April, 1865. 



A DICTIONARY OF THE TERMS USED IN MEDICINE 
AND THE COLLATERAL SCIENCES. By Richard D. Hoblyn, M. D. 
A new American edition, revised, with numerous additions, by Isaac Hays, 
M. D., Editor of the "American Journal of the Medical Sciences." In one 
large royal 12mo. volume of over 500 double-columned pages,- extra cloth, 
$1 50 ; leather, $2. 
It is the best book of definitions we have, and ought always to be upon the student's 

table. — Southern Med. and Surg. Journal. 



HENRY C. LEA-Philadelphia. 






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